Medico-legal - Managing the non-concordant patient

Achieve better compliance by engaging with problem patients, says medico-legal adviser Dr Richard Stacey.

Meaningful discussion with patients is a key step in concordance
Meaningful discussion with patients is a key step in concordance

Doctors' primary concern is to do their best for their patients. All practices will, however, have a cohort of patients whose autonomous choices conflict with the course of action suggested by their doctor.

There are two common scenarios in relation to non-compliance. First, the patient who having been started on a treatment declines to attend for subsequent review and/or monitoring. This puts a GP in an invidious position because a decision has already been taken that it is in the patient's best interests to commence a particular treatment.

The second scenario is the patient who declines the investigation or treatment of symptoms with a potentially serious and/or treatable underlying cause.

You may feel feel uneasy and frustrated but it is important to remember it is unlikely that a doctor will be legitimately criticised if a competent patient has made an informed decision to pursue a particular course.

The right to self-determination is reflected in paragraph 5[c] of the GMC's publication Consent: Patients and Doctors Making Decisions Together.1

The step-wise approach (see box below) to managing a non-compliant patient may help.

But, irrespective of this advice, there will still be a small group of patients who will pose a problem.

Should I refuse any further treatment?
This is one of the two questions commonly raised by members of the Medical Protection Society. Doctors should be extremely cautious about adopting such an approach.

The difficulty in this scenario is that the treatment has already been deemed of benefit to the patient and it may cause harm to the patient if treatment is suddenly withdrawn.

The retort to this would be that the patient is placing him or herself at risk of side-effects by not complying with follow-up. However, on the basis that this is an informed decision, the patient is entitled to take such a risk.

There are certain circumstances when it might be appropriate to refuse to prescribe - in the field of addiction, for example - but such an approach should only ever be taken with great caution.

Should I remove the patient from the list?
When an impasse seems to have been reached, it is not uncommon for a doctor to consider removing the patient from the practice list. However, this is fraught with difficulties and may leave you open to criticism.

The GMC states that you should not end a relationship with a patient solely on the basis of a complaint or because of the resource implications of care.2

In addition, the NHS (General Medical Services Contracts) Regulations 2004 introduced regulations in relation to the removal of patients from the list, stating there should be reasonable grounds for removal not based on the patient's medical condition, treatment needs, or workload implications.3

Removing the patient is unlikely to be helpful.

Summary
While managing non-compliant patients poses a challenge, if an understanding is reached between doctor and patient, it can be a cathartic experience. To protect themselves, doctors must ensure they can justify the approach and demonstrate they made the patient clearly aware of the risks of non-compliance.

  • Dr Stacey is a medico-legal adviser at the Medical Protection Society

This topic falls under section 3 of the RCGP curriculum 'Personal and Professional Responsibilities', www.healthcarerepublic.com/curriculum

Learning points

1. Be cautious about refusing further treatment.

2. Non-compliance is not grounds for removing the patient from the practice list.

3. Make every effort to engage with the patient.

4. Make sure you can justify your approach.

5. Document any discussions in the patient's record.

 

References
1. GMC Consent: Patients and Doctors Making Decisions Together, 2008.

2. Good Medical Practice, GMC, 2006.

3. Medical Protection Society, www.mps.org.uk

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