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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1324/97-98
Matters considered: Implementation of a change in policy with regard to patients wishing to see a female doctor; response to complaint about that
Complaint against: GPs in the North and Mid Hampshire Health Authority area
Complaint as put by Mrs D
1. The account of the complaint provided by Mrs D was that when she registered with a GP practice (the practice) in 1989 she was told that although, for administrative reasons, she could not register with the female general practitioner (GP) working in the practice at the time, she would always be able to consult a female GP if she wished to do so. Subsequently, Mrs D consulted several female GPs within the practice, but when she tried to make an appointment in August 1997 she was told that the policy had changed on 1 May 1997 and that she could now only see the GP with whom she was registered. On 13 August, in a letter which she copied to North and Mid Hampshire Health Authority (the Health Authority), Mrs D complained to the practice manager (the practice manager) about the change in policy which, she said, unreasonably denied her access to a female doctor unless she could demonstrate to reception staff that she had exceptional reasons for seeing a female doctor. The practice manager replied on 28 August but Mrs D remained dissatisfied and asked for an independent review of her complaints. On 15 October, the Health Authority's convener refused her request.
2. The complaint investigated was that implementation of the practice decision to change their policy on consultation with a female doctor was unsatisfactory in that:
- Mrs D was unaware of the change until she visited the surgery for a consultation and that the refusal of a female GP working at the practice at that time (the female GP) to agree to see Mrs D was unreasonable; and
- the practice manager's written response to Mrs D was inadequate in that it failed fully to address the issues she had raised.
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Investigation
3. The statement of complaint for the investigation was issued on 28 January 1998. The comments of all GP partners in the practice (the practice GPs), were obtained and relevant papers were examined. One of the Ombudsman's investigating staff took evidence from Mrs D, the female GP, a male GP with whom Mrs D was registered (the male GP) and staff of the practice.
Complaint (a)
Mrs D's awareness of the change and the female GP's refusal to see her. Mrs D's evidence
4. Mrs D told the investigator that when she first attended the practice in 1989 she asked to register with a female GP but was told that she could not do so as the female GP in the practice at that time had not been there long enough. She was told that if she registered with the first male GP, she would be able to see a female doctor whenever she wished. With that assurance, Mrs D registered with the practice. She seldom visited the practice, for she was able to use Well Woman and Family Planning Services at her place of work; but when she did go to the practice about general medical matters she readily saw whichever GP was available. She asked to see a female doctor for the first time on 13 August 1997 when she telephoned for an appointment. The receptionist told her then that she would be able to see only the GP with whom she was registered, and she asked why Mrs D wanted to see a female GP. Mrs D explained her reasons, although she felt uncomfortable doing so, but the receptionist still said that she could not make an appointment with the female GP.
5. Mrs D said that she asked to speak to the practice manager and, later that day, the practice manager telephoned her to explain that because of a change in the practice's policy Mrs D would have to see the male GP in future. The practice manager did not say why the policy had changed, or make allowance for the fact that Mrs D had only just learned of the change. Mrs D was upset by her uncaring manner and refusal to consider exceptions to the practice policy. The practice manager implied that she had asked the female GP, if she would see Mrs D, but that the female GP had refused because she had not seen her before. However, Mrs D doubted if anyone had consulted the female GP, or taken the trouble to consult her records which would have clearly shown that she preferred to see women GPs. Mrs D accepted that the practice was entitled to change its policy but considered that more could have been done to publicise the change. Although she had visited the practice in May 1997 she had not seen any publicity about it. She said that patients who visited the practice rarely, or were known to prefer GPs of a particular sex, should have been notified personally. They could then have made alternative arrangements if they wished.
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The practice GPs' formal response
6. The practice GPs' formal response to the statement of complaint, at the start of the Ombudsman's investigation, included:
'Prior to May 1997 it was the general practice policy that patients were largely expected to see their own doctor ... There was however a certain amount of interplay ... In particular we were aware that some female patients might wish to see a lady doctor ... this could obviously represent an inequality of workload ... but luckily the demand was not too great ...
'... a number of partnership changes over the last few years ... plus this general acceptance of patients sometimes seeing a doctor other than the one they were registered with, was found to be causing an increasing amount of confusion.
'[The female GP] was, as time went by, finding her workload increasingly more arduous due to a significantly increasing number of female patients wishing to see her.
'In May 1997 we therefore took the decision to implement a new policy whereby as far as possible patients would only see [their own doctor] for routine matters ... An obvious solution ... for a particular female patient might be to re-register with [the female GP] ... [but she] did not wish to find herself having an increasingly large "gynaecological" workload and as a general rule we therefore wished to discourage patients from re-registering.
'... we should have been more flexible and made allowances in particular circumstances such as this. Our concern was of course that should we set a precedent we might have too many people re-registering in this way ...
'We are sorry that Mrs D was unaware of the change ... but we did check with [the Health Authority] whether it was necessary to inform the entire practice population ... and were told this was not so, and we did try to disseminate the information as much as possible through a poster and Newsletter. '... we have had a general reappraisal of practice policy. ... we will need to be more flexible and make allowances in individual cases, either by re-registering the patient or at least allowing them to see our female partner (or conversely a male partner) if there are extenuating circumstances.
'... the changes made were done entirely in the interests of the patients' care, especially from a continuity point of view. They were certainly not intended to be obstructive in any way. We do however accept that they were too inflexible ...'
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Documentary evidence
7. I have seen that the change in policy was explained in a practice notice headed 'CHANGES TO THE APPOINTMENT SYSTEM AS FROM 1ST MAY 1997' (see paragraph 9). The notice says that from that date patients will, when possible, see their own doctor. It advises patients to re-register if they regularly see a different doctor; and it states that 'all doctors will be happy to speak to patients if there are problems'. The investigator saw that a copy was still displayed near the reception point when he visited the practice. I have also seen the May 1997 edition of the practice newsletter, which contained an article explaining the change in policy (see paragraph 9). In its introduction the newsletter states: 'Please borrow one of the covered copies to read while waiting in the surgery or take away a plain copy to read at home and to share with the rest of your household'.
8. The practice's current policy is set out in a document entitled 'POLICY WITH REGARD TO NEW PATIENT REGISTRATION ... AND TRANSFER WITHIN THE PRACTICE—AS FROM 1.2.98'. It includes: 'We do not actively encourage internal transfers unless you have been already seeing another doctor within the practice regularly, or the doctor with whom you wish to register has already consented. If you wish to transfer it will be subject to the recipient doctor's approval. ... [the practice manager] will be happy to approach the doctors concerned on your behalf if you wish.'
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Staff evidence
9. The practice manager explained that the practice GPs had decided at a practice meeting to change the policy from 1 May 1997. She had been present to discuss how the change might be advertised. As it was necessary to inform all patients individually about some policy changes, she had contacted the Health Authority to ask if that was necessary in this instance. The Health Authority said that it was not but suggested that the practice advertise the change in their public areas. (Note: the investigator checked with the Health Authority who confirmed that that would have been the advice given.) The practice manager said that several notices were put up in the waiting area, and an article included in the May issue of the practice newsletter (paragraph 7) which was also available in the waiting area; and she had sent a memorandum to reception staff advising them what to do after 1 May. (Note: I have seen that the memorandum directed reception staff to take the details of patients who wished to transfer to another GP within the practice and refer them to the practice manager for attention.) The practice manager said that she had subsequently spoken to several patients about the policy change; a number of telephone callers had been referred to the female GP for her to decide if it was necessary for her to see them.
10. The practice manager could not recall the detail of her conversation with Mrs D but said that it was a difficult conversation and that Mrs D had questioned how the new policy might affect her and other patients. The practice manager had spoken to the female GP about the matter but because of her heavy workload the female GP had been unable to see Mrs D. She could not recall what she said to Mrs D about that, or how their conversation ended, but she had understood that Mrs D intended to seek another GP elsewhere. The practice manager said that Mrs D's complaint was the only written complaint they received about the change in policy, but that it had highlighted the need for greater flexibility in the policy's implementation. The revised arrangements from February 1998 (paragraph 8) appeared to be working smoothly; no complaints had been received about them.
11. One of the practice receptionists (the receptionist) told the investigator that it was likely she had spoken to Mrs D on 13 August as she had been on duty that day, but she could not recall doing so. She said that most patients had seemed satisfied with the changed policy. If patients asked to see a particular doctor she told them that they could only see the GP with whom they were registered. If they refused to accept that, she generally put them through to the practice manager or asked them to put their request in writing. It was not her place to ask why a patient wished to see a particular doctor although quite often patients would give her that information. She never pressed callers about the reason for their request. Some patients preferred to talk to the practice nurses so she sometimes gave callers that option. Since Mrs D's complaint the policy had been made slightly more flexible (paragraph 8) as a result of which most requests to see a particular doctor had been granted.
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The female GP's evidence
12. The female GP told the investigator that when she joined the practice patients were free to consult whichever practice GP they wished. She had inherited a particularly large patient list, which the practice had tried to reduce, but the number of female patients asking to see her in preference to her male colleagues had kept her workload high. Because of that, her own patients had had to wait longer to see her than she would have liked. The policy introduced on 1 May 1997 had been intended to address this inequality in workloads and improve the continuity of patient care. At first she had continued to see patients whom she had seen previously but, later, it became necessary to apply the policy more strictly. However, even then, she saw some patients who were not registered with her—for example, if she was asked to do so by one of her colleagues. She could not recall speaking to the practice manager about Mrs D, but said it was likely that she had done so for the practice manager had spoken to her about several patients. She could not see all the patients who wanted to see her, but had never knowingly refused to see one who had a good reason to do so. If necessary, she spoke to patients on the telephone to establish their reason for wanting to see her. If there was no good reason she thought it was fair to insist on patients seeing their own GP.
The male GP's evidence
13. The male GP told the investigator that when the practice decided to insist on patients seeing their own GP they did not discuss any exceptions to the policy or what to do with requests from patients who were unaware of the change. Not wishing to set any precedents, they had at first operated the policy as strictly as possible. Mrs D's complaint had identified a need for greater flexibility and they now accepted that in some instances it was right for a patient to see a GP other than their own. Requests to see particular GPs were now considered, on their merits, by the GPs concerned.
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Findings (a)
14. In May 1997, the practice GPs introduced a new policy requiring patients to see only the GP with whom they were registered. My concern is whether, in Mrs D's case, that policy was implemented in a satisfactory manner. For the most part, I have concluded that it was. I have considered first, in the light of Mrs D's evidence that she was unaware of the change until she sought an appointment with a female doctor on 13 August, how the change in policy was notified to the practice's patients. The change was announced in the May 1997 edition of the practice newsletter and while that was not circulated to all patients, copies of it were made available in the patients' waiting area. I have been told that notices were put up in the waiting area; and although Mrs D has said she did not see those when she attended the practice in May, I do not doubt that they were displayed as one was still in place when the Ombudsman's investigator visited the practice. Placing notices in the public area was consistent with Health Authority advice and seems to me to have been an entirely appropriate method of announcing the change. However, I have also considered how the practice responded to Mrs D's request in August 1997 and, in that respect, I am concerned about the way in which the new policy was implemented. I cannot be certain exactly what was said to Mrs D, or whether the female GP was consulted before an appointment with her was refused, but, from the evidence I have taken, I think it likely that the new policy was too rigidly enforced and that little consideration was given to Mrs D's particular needs. That is unsatisfactory, particularly as she attended the practice infrequently and could not reasonably have been expected to be aware of the policy change. I am pleased to note that, in the light of Mrs D's complaint, the practice have recognised the need for greater flexibility, and have taken steps to make sure that each request to see a particular doctor is considered on its merits. To the extent that that was not done in Mrs D's case, I uphold the complaint.
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Complaint (b)
The practice manager's written response . Mrs D's evidence
15. Mrs D said that she wrote to the practice manager on 13 August because she remained dissatisfied following their telephone conversation earlier that day (paragraph 5). She complained that she did not know about the new policy until she telephoned to make an appointment. She said that the policy denied access to primary health care for people not prepared to discuss matters with a male doctor; and that the practice should accommodate such patients, particularly in the light of the closure of local family planning facilities. She asked the practice to review its policy, consider taking on additional female doctors and offer a more comprehensive 'well woman' and 'well man' service. She told the investigator that the practice manager's reply failed to address most of the points she had raised. It did not explain the reasons for the change of policy, or what the practice would do about patients like her who wished to see a specific GP; and it did not explain what consideration was given to her request for an appointment with a female doctor on 13 August before that was refused.
Staff evidence
16. The practice manager confirmed that she spoke to Mrs D by telephone on 13 August but could not recall fully what was discussed. She had recorded the call in the complaints register, but not the detail of the conversation. When Mrs D's written complaint arrived, she was on leave, but she replied immediately on her return. (Note: I have seen that in her letter she regretted the reduction in family planning services and explained the limitation of what the practice could provide in that respect. She explained, too, that the practice intended to appoint another doctor, who they hoped would be female; and that they hoped to set up 'well woman/well man' clinics in the near future. The letter said nothing about the change in policy or what consideration had been given to Mrs D's request to see a female doctor.) The practice manager acknowledged that her letter did not address all the issues raised by Mrs D and said that pressure of work may have affected the quality of her reply. She was sure, however, that she had explained the practice's position fully in their telephone conversation. With hindsight, that should have been restated in her written reply and she now took great care to make sure that all the issues raised by a complainant were addressed in the written response. She had shown her reply to the male GP and another GP in the practice before sending it to Mrs D and they had not suggested any changes.
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The male GP's evidence
17. The male GP who took responsibility for complaints within the practice, confirmed that he would have expected to see a written reply to a complainant before it was issued, but said that he could not recall seeing the reply to Mrs D. He agreed that the reply had not addressed all the issues Mrs D had raised, but said that the practice had learnt a lesson from her complaint.
Findings (b)
18. I cannot say whether Mrs D's concerns were adequately addressed in the telephone conversation she had with the practice manager, but there is no doubt that the practice manager's written reply did not address all the issues Mrs D raised in her letter of complaint. In particular, it failed to offer any explanation about the new policy, or what consideration had been given to Mrs D's request to see a female doctor. Both the practice manager and the male GP have recognised the reply's shortcomings. I accept that lessons have been learned for the future, and I am content to leave the matter there. I uphold the complaint.
Conclusion
19. I have set out my findings in paragraphs 14 and 18. The practice GPs have asked me to convey through my report—as I do—their apologies to Mrs D for the shortcomings I have identified.
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