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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1934/97-98
Matter considered: GP's removal of patients was unreasonable
Complaint against: A GP in the Calderdale and Kirklees Health Authority area, Yorkshire
Complaint as put by Mrs P
1. The account of the complaint provided by Mrs P was that on 2 January 1997 Calderdale and Kirklees Health Authority wrote to her parents, Mr and Mrs Q, informing them that they were to be removed from the list of NHS patients of their general practitioner (the doctor). When Mrs Q asked the doctor's practice for an explanation, the practice manager told her that the practice did not want to have to deal with Mrs P should Mr and Mrs Q make a complaint against the practice. Mrs P had previously complained about the senior partner at the practice, on behalf of her late mother-in-law. Mrs P had then removed herself from the list of the practice, where she had also been a patient. Mr and Mrs Q did not think that the earlier complaint should have affected them.
2. The matter subject to investigation was that the doctor unreasonably removed Mr and Mrs Q from his list.
Investigation
3. The statement of complaint for the investigation was issued on 19 March 1998. The doctor's comments were obtained and relevant papers examined. The Ombudsman's staff took evidence from Mrs P, Mr and Mrs Q, the doctor and the senior partner at the practice. I have not put into this report every detail investigated but I am satisfied that no matter of significance has been overlooked.
4. The National Health Service (General Medical Services) Regulations 1992, Schedule 2, Terms of Service for doctors, states:
'... 9 (1) A doctor may have any person removed from his list and shall notify the [Family Health Services Authority (superceded by the Health Authority)] in writing that he wishes to have a person removed from his list ...'
5. Advice to GPs from the General Medical Services Committee (GMSC) which is the elected representative body of GPs, states:
'... The removal of patients from GPs' lists should continue to be an exceptional and rare event, and a last resort in an impaired doctor-patient relationship ...
'...
'Other members of the household 'If the behaviour of one member of a household or family has led to their removal, GPs will need to use their judgement about other members. Sometimes an explicit discussion with other family members about the problem and the choices which they have will be helpful.
'In many cases, however, because of the duty to visit patients at home it may be prudent to terminate responsibility for the entire household or other members of the family. Again the GMSC would suggest that reasons are given.'
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6. In June 1997 (ie after the events in this case) the Royal College of General Practitioners (RCGP) issued guidance to members on the removal of patients from GPs' lists. A section listing the situations which do not normally justify removal includes 'Where a patient ... complains via the In-House complaints system.' The guidance advises GPs, when considering removing patients, to 'inform the patient personally that there is a problem and consider arranging a meeting to discuss matters. It may be considered more appropriate to inform the patient by letter ... Attempt to explain to the patient the nature of the problem ... Be prepared to negotiate with the patient over specific problems ...'
7. Guidance at the relevant time from the General Medical Council on 'Good Medical Practice' said that doctors must:
'respond to criticisms and complaints ... constructively'.
8. Mr and Mrs Q (who live in a different street from Mrs P) said they were shocked when they received a letter from the Health Authority telling them that they were to be removed from the doctor's list. They had experienced no problems in their relationships with the doctor, nor had they ever complained about him or any other GP at the practice. They had been with the practice for over forty years and on the doctor's list for a few years. They did not think their daughter's complaint should have affected them in any way. Mrs Q had seen the doctor regularly because of her diabetes and high blood pressure. Mr Q said he had seen the doctor on only one occasion, a home visit, but had attended the practice once or twice a year for check ups in connection with a heart condition. Having been removed from the doctor's list, they had now registered with a new GP and did not wish to return to the doctor.
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9. In his formal comments at the beginning of this investigation, the GP wrote:
'The decision to terminate my contract to provide general medical services to the Qs was taken after discussion with my partners. Their daughter, Mrs P, had acted in an unreasonable manipulative and critical manner with regard to the management of her mother-in-law's illness culminating in a complaint against [the senior partner] ...
'It was decided that Mrs P was clearly dissatisfied with the practice and that the situation would inevitably arise ... when she would make similar demands on behalf of her own parents, a situation [to] which we were not prepared to expose the practice.'
When interviewed the doctor said he had experienced no problems in his relationships with Mr and Mrs Q. He did not know whether Mrs P had a close relationship with her parents. He saw Mrs Q regularly, about four times a year. However, he had seen Mr Q only once, about five years ago.
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10. In later comments the doctor said that he considered that it was significant that (in the opinion of the practice) Mrs P had 'abused the service' offered by the practice on four occasions. (He referred to requests for visits and to complaining about her mother-in-law's care.) He said that Mrs P had been advised that 'should she submit a complaint she and all her family would have their contracts for general medical services with the practice terminated'. He saw the complaint as a fifth example of vexatious behaviour by Mrs P.
11. He said that the majority of the partners at the practice were not members of the BMA or RCGP as they did not recognise them as being representative of opinion in general practice. He pointed out that the guidance of the professional bodies in paragraphs 5 and 6 need not be followed.
12. The senior partner said the decision to terminate the contract to provide general medical services to Mr and Mrs Q was a direct consequence of the complaint Mrs P made about his own actions concerning the management of her late mother-in-law's care. The decision was made following discussions within the practice. Although Mr and Mrs Q were not particularly demanding patients, as they were getting older it was inevitable that Mrs P would become involved in the management of their care and, at some point, make a complaint about the practice. At the time the decision was made neither he nor his partners had any knowledge of the strength of the relationship between Mrs P and her parents. No enquiries had been made of Mr and Mrs Q about that. He had, however, known that Mrs P's complaint about her mother-in-law's care was the only one she had made to the practice.
13. When corresponding with Huddersfield Community Health Council in respect of the original complaint made by Mrs P, the Health Authority said that they agreed that the practice had not dealt with that complaint 'within the spirit of the NHS complaints procedure'. (The doctor has commented that the in-house complaints procedure had been correctly applied, but that the complaint could not be resolved informally.)
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Findings
14. The GPs' terms of service entitle them to remove patients from their lists. The Ombudsman does not question that entitlement; but he takes the view that as providers of a public service, GPs should act reasonably in what they do, including deciding whether to remove patients from their lists. He believes that this is broadly in line with the professional bodies, whose views are described in paragraphs 4-7. Even if they are not binding on GPs, I consider that it is appropriate for me to bear in mind the expressed views of such significant professional bodies. Having informed myself about those views, I have made my own judgment. The question for me is whether the GP acted unreasonably in removing Mr and Mrs Q.
15. Mr and Mrs Q were removed from the doctor's list, not because of any failure or action on their part, but because of their daughter's actions. The GPs believed that Mrs P would eventually become involved in her parents' care and complain unreasonably about that. Clearly there are very different views about who was to blame for the original difficulty between Mrs P and the practice, and about how her complaint was handled. I note with grave concern the comment made to me by the practice that they had told Mrs P that she and her family would be removed from the list if they complained. That certainly is neither in the spirit of the NHS complaints procedure, nor in line with guidance from the General Medical Council (paragraph 7).
16. I have noted the GMSC's advice to GPs that the removal of one member of a family may mean that it is prudent to remove other family members, because of the duty to visit patients at home. However, in this case Mrs P actually removed herself from the doctor's list, the Qs and Mrs P did not share a home, and the GPs accept that they knew nothing about the strength of the relationship between Mrs P and her parents. Although the practice may have perceived other causes for concern, Mrs P had complained to the practice only once: there was no pattern of repeated vexatious complaints. Nor can I see that the breakdown in relationship between Mrs P and the practice should necessarily have meant that the doctor's relationship with her parents had to end. The doctor did not attempt to discuss the situation (as suggested by the GMSC and RCGP, paragraphs 5 and 6) with the Qs before they were removed, or even write direct to them with the decision. As it was, the news of their removal came as an unexpected and unwelcome shock to an older couple, who had been on the practice's list without difficulty for many years.
17. In my view the doctor did not give adequate consideration to all relevant matters (as described above) before deciding to remove Mr and Mrs Q from his list. Therefore I consider that the removal was unreasonable. Mr and Mrs Q would not now wish to return to the doctor's list. I uphold the complaint.
Conclusion
18. I have set out my findings in paragraphs 14-17. The doctor remains of the view that the decision to remove Mr and Mrs Q from his list was correct, and he has declined to offer the apology which I had suggested was appropriate. He accepts that he could have informed Mr and Mrs Q in more detail of the reasons for his decision.
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