Part of the beauty of general practice is its sheer unpredictability. You just don't know who will come through the surgery door next.
Temporary patients, be they relatives of existing patients, holidaymakers, homeless people, or asylum seekers, present greater medico-legal challenges, not least because they are unknown to you and you may not be able to gain access to their medical records.
Contractually, GPs can refuse to treat temporary patients provided they have 'reasonable grounds for doing so that do not relate to the applicant's race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition' (clause 181, standard GMS contract). However, GPs have a contractual duty to provide immediate necessary treatment and an ethical duty to treat in an emergency.
Take the following fictional cases based on examples from the MDU's files, which illustrate where problems can arise with non-registered patients.
Case one: a holidaymaker
A GP saw a tourist who was not registered with the practice and who requested a prescription of his antihypertensives.
The patient explained he had extended his holiday and did not have enough tablets with him and needed to get some more to 'tide him over' until he returned home. The GP provided a prescription for the dose of beta-blocker the patient said he was taking to be taken 'as directed'.
Unfortunately the patient mistakenly told the GP a higher dose than he was usually prescribed and also took the drug twice a day, instead of the once daily dose that he routinely took.
The GP received a call two weeks later from the patient's usual GP explaining that the patient had been hospitalised after a fall as a result of the higher dose of medication.
The GP rang the MDU for advice about handling the adverse incident. The adviser explained that the practice might like to hold a significant event analysis meeting about the incident. As a result of the meeting, the practice reviewed its procedures for treating temporary residents.
They agreed that it would be good practice to contact the patient's own GP, with the patient's permission, before issuing prescriptions in cases where this was possible, to check the history, dose of drugs and allergy status of the patient. A note should be made in the record about such a discussion.
The practice also reviewed its policy on prescribing to ensure that both dose and frequency were always specified on prescriptions.
Case two: an asylum seeker
Another GP saw a temporary patient who had a foot problem. During the consultation, the man revealed he was a failed asylum seeker. The GP examined the patient, who was a diabetic with an infected foot ulcer, and decided that treatment was immediately necessary.
She rang the MDU to ask if there were any medico-legal issues to be aware of in treating a failed asylum seeker. The adviser referred the GP to recent DoH guidance on asylum seekers which states that "immediately necessary and urgent medical treatment" should never be withheld, but should be limited to that which is necessary for the person to return to his or her own country.1
Continuity of care
When treating any temporary patients, it is important to ensure that the patient's own GP, if they have one, is kept informed to ensure continuity of care.
The GMC's Good Medical Practice (2006) advises in paragraphs 52 and 53 that, unless the patient objects, their GP should be informed about the results of investigations, treatment provided and any other information necessary for continuing care.2
If the patient has not been referred to you by their GP, you should seek consent to inform their GP before starting treatment, except in an emergency when it is impractical to do so.
If a patient refuses to give permission, you may decide to ask the patient why. In its confidentiality guidance, the GMC says: 'You must respect the wishes of a patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm' (paragraph 10).3
- Dr Old is a medico-legal adviser at the Medical Defence Union. the-mdu.com
- This topic falls under section 3.3 of the RCGP curriculum 'Clinical Ethics and Values-Based Practice', healthcarerepublic.com/curriculum
1. GPs can refuse to treat temporary patients provided they have 'reasonable grounds for doing so'.
2. GPs have a contractual duty to provide immediate necessary treatment and an ethical duty to treat in an emergency.
3. Keep the patient's own GP informed and document any discussion in your notes.
4. Remember to seek consent before contacting the patient's GP.
1. Failed asylum seekers and ordinary/lawful residence; and when to provide treatment for those who are chargeable, DoH dear colleague letter, 2 April 2009
2. GMC. Good Medical Practice 2006 www.gmc-uk.org/guidance/good_medical_practice.asp
3. GMC. Confidentiality 2009 www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp