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prompted for example by the patient being threatening, abusive or violent, persistently acting inconsiderately or unreasonably, stealing from the premises or making sexual advances towards a member of staff. Patients should not be deregistered simply because they have made a complaint or a claim, or because their medical needs are burdensome.
• Every attempt should be made to restore the relationship or consider alternatives.
• A warning should be given that you are considering ending the relationship.
• When the decision has been made, the reasons should be explained to the pa- tient in writing.
• When documenting the circumstances into the patient’s records, the entries should be factual and not written in a way that may unfairly prejudice future care. The GMC also states that you must
make prompt arrangements to ensure the continuing care of the patient and pass on the patient’s records to a new practice without delay.
MEDIATION FIRST One key element in all the guidance dealing with the breakdown in the practice-patient relationship is the need for a genuine attempt to resolve any issue that may have led to the
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impasse – to avoid that “knee jerk” reaction to “difficult” patients. The NHS Choices website informs patients: “you have the right to complain, have your complaint investigated, and be given a full and prompt reply.” Not only this but patients have the right to expect that making a complaint will not prejudice their ongoing care. Our advice to practices in dealing with
“difficult” patients is first to open a dialogue. Invite the patient to attend the practice for a discussion and try to get at the root of the problem. Sometimes there may be some un- derlying issue, such as a previous grievance. It may not even have to do with the patient themselves but with a family member. Some patients may also have unreal expectations of the service you are providing – for example that care should always be offered by a doctor rather than a practice nurse. You should also consider the patient’s personal circumstances, bearing in mind any known physical or mental health conditions that may explain the reason for the difficult behaviour. Have they suffered a recent be- reavement or job loss or marital breakdown? To avoid charges of prejudicial treatment it is important to demonstrate you tried to mediate and resolve the breakdown in the relationship with the patient. There should be some discussion of possible ways of moving
forward constructively and these discussions should be documented before making any decision to deregister. Other alternatives to removal should be
considered such as transferring the patient’s care to another partner (with the consent of both parties) or persuading the patient that it would be better for all concerned for he or she to attend another practice. In any case, it would be wise to get some advice before considering the deregistration of any patient and remember that MDDUS advisers are on hand to discuss such matters.
Scott Obrzud is an MDDUS practice adviser and co-editor of Practice Manager FURTHER RESOURCES
• British Medical Association – General Practitioners Committee (GPC) Removal of patients from GP lists
• Department of Health - Health service cir- cular 2000/001 Tackling violence towards GPs and their staff
• General Medical Council - Ending your pro- fessional relationship with a patient (2013)
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