Practice dilemma: A decision between partners

One GP partner agrees to see a patient excluded by the practice. How should this be resolved?

At a practice meeting it is decided the patient should be excluded from the practice (Photograph: iStock)

A woman with a sedentary job has a back injury. After several weeks of certified sick leave, you believe she has recovered and sign her as fit to return to work. You explain that she does not need a phased return to work.

Her reaction to this is extreme and she shouts insults before storming out. At a practice meeting it is decided she should be excluded from the practice.

Some weeks later you see this patient waiting to see another partner. The partner says they felt sorry for her and thought they would take her over as a patient.

You are troubled by this, as you do not have personal lists and you might not be able to avoid having to see this patient again.

What should you do?

A GP’s response: Dr Zara Aziz is a GP in Bristol

Several issues are highlighted in this dilemma. There has been a breakdown in the doctor/patient relationship, resulting in a joint decision by all the partners to ask this woman to register with another surgery. It is important that all partners respect and abide by such jointly made decisions. It is inevitable that at times individual decisions are later questioned, but these should be brought to the attention of the other partners.

Abusive behaviour should never be condoned, but there may have been genuine reasons for this woman’s outburst and a case could have been made to keep her as a patient if she was remorseful.

The second partner should have discussed their change of heart with the others before committing to a decision without their support or knowledge. It is crucial for partners to have open discussions and reach agreement on a wide variety of issues.

A meeting should therefore be called to discuss what might have gone wrong and to review existing practice policy on the removal of patients from GPs’ lists. The emphasis should be on auditing problematic cases, consulting other team members and offering the patient a chance to come in to voice their views.

As doctors, we have a duty of care to our patients. As some time has elapsed, it would be unfair to ask this woman to leave the practice, though it could be made clear that she should see other doctors within the team.

A medico-legal view: Dr Andrew Power is a medico-legal adviser at the Medical Protection Society

There are two distinct issues raised in this case: the removal of patients from the practice list and working with colleagues. The regulations in the GMS contract of 2004 are detailed, but in essence there is one set of rules for people who have been violent or threatening and another for all other circumstances.

Although being verbally abusive may constitute grounds for removal, the contract and RCGP guidance are both clear that a warning letter should be sent in the first instance.

It is only if patients have been ‘violent or threatening to the point where there have been fears for personal safety’ that the incident must be reported to the police and immediate removal can occur.

In this case, the patient remains on the practice list and this is an opportunity to retrace some steps and send a warning regarding her behaviour. Should another episode occur, the partners could request her removal, and this would take place eight days after receipt of a written statement of intent by the PCT or when she is accepted on to another practice list.

Good Medical Practice stresses the importance of teamwork and communication. This case raises a learning point for the practice as a whole with regard to the practice policy for the removal of patients and how the practice makes decisions, communicates them and acts consistently.

This should be written up and discussed as a significant event analysis. It is an opportunity to review and update the policy and the practice leaflet so it is clear for all staff and patients.

A patient’s opinion: Danny Daniels is an expert patient

Unfortunately, the scenario does not feature any of the steps that should have been taken in order to ensure that acceptable procedures were implemented.

The following, in my opinion, are the questions that should be raised:
Does the practice have clear patient removal procedures? (Are they up to date on codes of practice?)

Does the practice leaflet feature information on acceptable behaviour and the consequences incurred should behaviour not be acceptable?

Does the patient actually know that she demonstrated levels of unacceptable behaviour?

Have there been any previous problems with the patient and, if so, have written warnings been issued? Was there any attempt to mediate?

Why was the doctor not informed of the practice decision to rescind its original decision?

Perhaps it is too late now to remove the patient from the practice list. The doctor has been presented with a dilemma because of the practice decision and the GP’s problem has become an issue with the partners.

I suggest that the doctor should, in the first instance, meet colleagues to explore all factors and attempt to arrive at a solution that is fair to patient and doctor, and which will address the emotional and ethical ele­ments in a satisfactory manner.

An undertaking by the practice that the doctor is protected by not having to consult with the patient may well be impractical. It is in the interests of the practice to review its current procedures.

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