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Selected Investigations Completed April - September 1999 > Part II, Case no. E.2449/98-99
Complaint against: A GP in the Avon Health Authority area
Complaint as put by Mrs K
1. The account of the complaint provided by Mr K was that he complained, on his daughter's behalf, to the Health Service Ombudsman about the care and treatment she had received from the deputising service used by their GP, Dr J. On 28 January 1999 Dr J was sent a letter from this office to inform him that it was proposed that the complaint should be investigated by the Ombudsman.
2. On 29 January Dr J wrote to Mr K, suggesting that he register with a different GP practice. On 18 February, after correspondence, Dr J wrote to Mr K informing him that he would be removed from the practice list and should register elsewhere.
3. The matter investigated was that Dr J acted unreasonably in removing Mr K from the practice list.
Investigation
4. The statement of complaint for the investigation was issued on 8 April 1999. Dr J's comments were obtained and relevant papers examined. The Ombudsman's staff took evidence from Mr K and from Dr J and his partners.
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Guidance
5. The National Health Service (General Medical Services) Regulations 1992, Schedule 2, Terms of Service for doctors state:
'.... 9 (1) A doctor may have any person removed from his list and shall notify the [Health Authority] in writing that he wishes to have a person removed from his list ....'
6. Advice to GPs from the General Medical Services Committee (GMSC), (which was 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.'
7. A booklet on good medical practice, produced by the General Medical Council (GMC) in July 1998 states:
'.... As a doctor you have a professional responsibility to deal with complaints constructively and honestly. You should co-operate with any complaints procedure which applies to your work. You must not allow a patient's complaint to prejudice the care and treatment you provide or arrange for that patient.
....
'You must do your best to establish and maintain a relationship of trust with your patients. Rarely, there may be circumstances in which you find it necessary to end a professional relationship with a patient ....'
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8. In June 1997 the Royal College of General Practitioners (RCGP) issued guidance on the removal of patients from GPs' lists. That guidance states that when a patient complains through the in-house complaints procedure, that does not normally justify the patient's removal from the GP's list.
Documentary Evidence
9. Dr J's letter of 29 January included:
'I have today received notification from the Ombudsman's office that a complaint against me is to be investigated ....
'This complaint will obviously cause myself .... and the practice great stress. I feel that the "doctor-patient relationship" has been irrevocably damaged and that we shall not, in the future, be able to give you the care and consideration that we have strived to do in the past.
'On reading the complaint it is evident that you are unhappy with our arrangements for providing "out of hours" medical cover.
'In view of both the above comments you may therefore feel it to be appropriate to consider registering yourself with a practice that does not make use of such arrangements.'
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10. On 1 February Mr K replied and stated:
'.... you will be aware that .... my own personal health was far from good, particularly [from] late summer 1997 to late spring 1998.
'During that time the care and consideration of yourself [and one of your partners] was excellent. I would go further and say that without that care and consideration .... I firmly believe I would have died or my quality of life would have been unacceptably poor.
'At no time did I question my doctor-patient relationship because of my .... grievance with [the deputising service].
....
'If I must register with a different practice that will be really sad after 27 years. Can I take this opportunity .... to thank you .... and all the staff for their kindness shown me and I wish you all well.'
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11. Dr J replied on 18 February when he wrote:
'Thank you for your recent letter which we have considered. We feel that the comments made in my first letter still stand and thus feel that we have to remove you from our list.'
12. In comments to the Ombudsman at the start of this investigation Dr J wrote:
' .... Mr K had a consultation with [me] on 27 January 1999. During that consultation I felt emotionally threatened, anxious and angry, even though at that stage Mr K thanked me for his past care and I did not know of the Ombudsman involvement in his .... complaint. Like many GPs I find complaints the most stressful part of general practice .... The next day I received [the] letter informing me of your decision to look again at Mr K's complaint. I felt, and still do feel, that it would be unprofessional of me to remain Mr K's GP .... I felt that I would not be in a position to remain objective and therefore able to provide the best care and attention that all patients .... deserve .... I felt that it would be prudent for Mr K to register with another practice locally .... I did not want him to lose continuity of medical care and therefore wanted to offer him the opportunity to re-register in his own time with a proper hand over of care by myself to his future GP. I still feel .... that this was the correct and professional course of action ....
'I wish to make it clear that I and my partners did not lightly make the decision to remove Mr K from the list. The issues were discussed between all partners .... The practice rarely removes patients from the list. Indeed we pride ourselves on trying to keep all our patients on the list despite the occasional difficulties. I have not, in six years of being a GP, previously asked any patient to leave my list ....'
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13. Mr K said he rarely saw Dr J when he attended the surgery; he normally saw one of the other partners. There had never been a problem with the service received in normal hours. He felt that he should not have been removed from the practice list when all he had done was to follow the complaints system. He could not understand why the decision to remove him happened only when the Ombudsman decided to investigate that complaint, after he had been through the local complaints system. There had not been any discussion between him and the practice about the possibility: they had simply removed him from the list. Dr J's suggestion, that he should register with a GP practice with different arrangements for medical cover outside normal hours, was ridiculous; all the GP practices in the area used the same service.
14. Dr J said he felt edgy about seeing a patient who felt the way Mr K did. He would always be on his guard and there was a danger that they might not provide the standard of care Mr K deserved: unnecessary investigations might be carried out or Mr K might be referred unnecessarily for treatment elsewhere. That was why the practice removed him from their list.
15. Dr J said that he understood the reasons why Mr K first complained about his daughter's treatment. They did not then remove him from the list. But then the complaint seemed to be going on and on. He already felt edgy before Mr K's complaint to the Ombudsman and could not understand why the complaint continued as it did. It was then that Mr K was removed from the list. It was better for Mr K to receive his care from GPs at another practice, who knew nothing about the complaint and had different out-of-hours arrangements. He might have been able to find a practice which did not use the deputising service to the extent that Dr J's practice did.
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Findings
16. Mr K complained about the way his daughter had been treated by the deputising service used by the GP practice with which she and her father were registered. That complaint was dealt with under the NHS complaints procedure, and when Mr K remained dissatisfied he complained to the Ombudsman, as was his right. When this office wrote to Dr J to say that complaint would be investigated, Dr J wrote to Mr K asking him to find a new GP. He persisted in that view even when Mr K wrote a conciliatory letter, saying how much he valued the practice's service, and making it clear that he had no complaint about the actions of any of the practice's members.
17. A GP has the right to remove a patient from his list and has no contractual obligation to give prior notice of his intention. However the Ombudsman takes the view that, as providers of public service, GPs within the NHS should deal with such matters in a reasonable way. Patients should be able to make complaints in a reasonable fashion and have them considered, both by the NHS complaints procedure and by the Ombudsman, without the fear that they will be struck off their GP's list.
18. I recognise that being complained about is stressful and that Dr J had concerns about the effect that that would have on him and the possible impact on his ability to treat Mr K properly. However the complaint was not about Dr J's own actions or those of another doctor in the practice (but the actions of a deputising doctor, acting on Dr J's behalf). Mr K had not put his complaint in an unreasonable or aggressive way. Furthermore, as the GMC says, doctors should deal with complaints constructively and should not allow a patient's complaint to prejudice the care provided. I cannot see that Dr J approached the situation constructively or made any significant effort to maintain the relationship. Once Mr K pursued his complaint as far as this office and it agreed to investigate, he decided to remove Mr K from his list. That was not reasonable. Furthermore, the suggestion that Mr K might find another GP who did not use the out of hours service seems to have been impracticable. Mr K is to be congratulated for his very reasonable and conciliatory response to Dr J's first letter. However even with that very strong indication of Mr K's continued faith in the GPs in the practice, nothing was done to reconsider whether the doctor-patient relationship really was so badly damaged as Dr J feared and whether it really was necessary to take the exceptional step of removing Mr K from the list. I believe that the decision was wholly unreasonable. I uphold the complaint.
Conclusion
19. I have set out my findings in paragraphs 16 to 18. Dr J has asked me to convey - as I do - his apologies to Mr K for the shortcomings I have identified.
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