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Selected Investigations Completed April - September 1998 > Part II, Case no. E.42/97-98

Part II - Full Texts of Selected Investigations

Case No. E.42/97-98 - General practitioner's manner during a consultation and removal of patient from his list

Matters considered: GP's actions and manner during a consultation and the way in which he removed a patient from his list

Complaint against: A GP in the Ayrshire and Arran Health Board area

Complaint as put by Mr A

1. The account of the complaint provided by Mr A was that during a consultation on 21 January 1997 his general practitioner (the GP), behaved in a rude and unprofessional way towards him. Mr A then received a letter dated 22 January from Ayrshire and Arran Health Board telling him that the GP had requested his removal from his patient list. Mr A complained to the Health Board. He was not satisfied with the reply and on 1 May he requested an independent review. On 12 June the Health Board's convener wrote refusing an independent review.

2. The complaints investigated were that:

1. the GP acted inappropriately at the consultation on 21 January; and
2. his removal of Mr A from his list was unreasonable.

3. The statement of complaint for the investigation was issued on 1 September 1997. The Ombudsman obtained the comments of the GP and relevant papers were examined, including Mr A's medical records. One of the Ombudsman's investigators took evidence from Mr A and from the GP and his receptionist (the receptionist).

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Statutory position and guidance

4. The terms of service for general medical practitioners are set out in schedule 1 to the National Health Service (General Medical Services) (Scotland) Regulations 1995. Paragraph 9(1) of the schedule states in part

'... a doctor may have the name of any person removed from his list by giving notice to the Board ...'

'Inform the patient personally that there is a problem and consider arranging a meeting to discuss matters ...',

'Attempt to explain to the patient the nature of the problem ...',

'Try to elicit the patient's perspective and interpretation of the situation.', and

'... if discussion fails to resolve the problem'

'Suggest that another GP within the practice might better fit with the patient's needs and expectations.'

6. Advice from the General Medical Services Committee (the elected representative body of general practitioners) on the removal of patients from GP lists, issued in September 1996, includes 'There is no contractual obligation to give reasons for the request [to remove a patient] ... The GMSC recommends that ... GPs ... consider sending a brief letter to the patient informing them of the removal and briefly outlining the reasons ... [This] is a matter of common courtesy'.

7. In a guidance booklet on 'Good medical practice', issued in October 1995, the General Medical Council say 'Because the doctor-patient relationship is based on trust you have a special responsibility to make the relationship with your patients work'.

Mr A's evidence

8. Mr A told the investigator that at his consultation with the GP on 21 January 1997 he described his symptoms and told the GP that he thought he had flu. The GP examined him and said that he should take paracetamol. Mr A explained to the GP that he was reluctant to take paracetamol and asked if he could have something else like antibiotics. The GP gave him a prescription. On arrival home Mr A discovered that he had been given only ibuprofen. He thought that the GP had forgotten to put antibiotics on the prescription. He telephoned the surgery and a staff member asked him to call back later because the doctor was busy. However, he decided to go back to the surgery.

9. Mr A said that when he returned to the surgery the GP agreed to see him. When he went into the consulting room the GP asked 'What's wrong with you now?'. Mr A explained that the prescription had not included an antibiotic. The GP told him to take paracetamol and said he was not going to give him an antibiotic. Mr A explained that he was feeling awful, but the GP said 'Just go away and see another doctor and tell him your problems'. Mr A asked if that was all he had to say and the GP slapped his hand on the table and said 'Just go away'. He told the GP that he was not questioning his diagnosis but that the GP was not providing him with much support. He also asked the GP to put in writing that he should go to another doctor. The GP said that he would do that via the Health Board. No one else had been present during this exchange. Mr A described the GP's manner as abrupt and condescending. If the GP had told him in a reasonable manner that he did not need antibiotics he would have accepted that. As a result of what happened at the consultation, Mr A had lost faith in doctors, and had not registered with another GP until about September 1997, although his symptoms had lingered on and off for most of the year. He was now registered with a practice about seven miles distant.

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The GP's evidence

10. The GP's written response to the Ombudsman is appended to this report.

11. The GP told the investigator that Mr A registered with him in May 1996. He saw him a total of five times and there had been no problems before 21 January 1997. On 21 January Mr A complained of having had a flu like illness for the past week and that he had been delirious. He had chest pain and wondered whether a chest x-ray was necessary. On examination the GP found that Mr A's chest was clear, his blood pressure was fine and he had no fever. He concluded that Mr A had a viral infection. Mr A said that he was taking paracetamol; and the GP advised him to continue taking paracetamol and gave him a prescription for ibuprofen. Although Mr A thought that he should have antibiotics the GP explained to him that they were not necessary.

12. The GP said that within an hour Mr A telephoned the surgery saying that the medication he had been given would not work. He returned to the surgery and the GP took him into his room. They did not sit down throughout the meeting. Mr A said that ibuprofen would not work, and the GP told him that he did not need anything else. Mr A complained of pains in his rib cage and kept repeating that the prescription would not work. He wanted antibiotics. He had a bullying manner. The GP explained to him that he had examined him and that he did not have a chest infection so did not need antibiotics. Mr A would not accept his advice. The GP eventually told Mr A that in that case he would be better to find another doctor. Mr A said 'Just like that ?', and the GP replied 'Yes, in fact I'll write to the health board'. Mr A then walked out. The GP denied slapping his hand on the desk and considered that he dealt with Mr A as appropriately as he could. He had made a correct clinical decision which Mr A would not accept.

13. The GP confirmed that he had removed only 12 patients from his list over 13 years. Normally he would do so only if matters reached the stage where he could not do anything else for the patient. That stage was reached when either communications with the patient had irretrievably broken down or the patient did not trust his clinical judgement or would not follow his advice. He normally met the patient face to face and explained why he was going to remove them from his list. In Mr A's case their meeting was quite confrontational and they came to an impasse. There was no scope for further discussion with him. The GP did not discuss the decision with his partners because Mr A was registered with him. He did not consider alternatives because, once he decided to remove Mr A from his list, it was up to Mr A to find another doctor. In the circumstances he felt that the doctor /patient relationship had irretrievably broken down.

14. The receptionist said that when Mr A returned to the surgery his manner was unpleasant. She thought that the GP took him into his room because Mr A was speaking loudly.

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Findings (a)

The GP's attitude

15. Mr A complained that on 21 January the GP acted inappropriately. The GP has denied the allegation. Clearly the meeting became fraught; and each perceived the manner of the other to be inappropriate. However, in the absence of any other source of evidence I am unable to make a finding on this aspect of the complaint.

Findings (b)

Removal from the doctor's list

16. A GP is entitled to remove a patient from his list. He does not have a contractual obligation to give prior notice of his intention to do so, nor is he obliged to give reasons for taking such action. However, the Ombudsman's remit in investigating a complaint about a GP is to consider whether his or her action has caused hardship or injustice to the complainer. The Ombudsman takes the view that, as providers of a public service, GPs within the NHS implicitly accept an obligation to observe certain standards. Removal of a patient from a GP's list is a serious matter. He looks to see whether the GP has exercised his right to remove a patient reasonably and responsibly; and one aspect of that would be whether the GP had acted precipitately or disproportionately.

17. In his written response to the Ombudsman the GP said that he felt that his only alternative was to suggest to Mr A that he should register with another doctor. I recognise that the GP faced a difficult and challenging situation. However, I consider that when Mr A continued to stress what he perceived to be the problem and to ask for antibiotics, the GP decided, on the spot, that Mr A should be removed from his list of patients. The GP had not had any problems with Mr A in the past; and I am concerned that such a serious decision should have been taken in what appears to have been the heat of the moment. I consider that the GP acted precipitately in removing Mr A from his list without further discussion or considering alternatives. It would, for example, have been reasonable for the GP to have concluded the meeting by telling Mr A that he could change doctors if he would not accept his advice, or at least to have allowed a 'cooling off' period to consider other options before taking a final decision. To that extent I uphold this complaint.

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Conclusion

18. I have set out my findings in paragraphs 15 to 17. The GP has informed me that he is not prepared to apologise for the shortcomings I have found.

ANNEX TO S.42/97-98

The GP's official response to the Ombudsman

'A). Brief Summary Setting My Account Of The Action Complained About

'[Mr A] attended my surgery on the 21 January 1997. He complained of having had a "Flu like illness" for the past week. He said he had been delirious during the past week, but this had now settled. He still had a cough productive of clear catarrh and left sided chest pains. He also mentioned that he had had a previous injury to his left chest and wondered whether he required a chest x-ray.

'On examination he was afebrile [did not have a fever] and not distressed. Auscultation [listening to the chest with a stethoscope] of the chest was clear, his blood pressure was 120/80. He was tender over his left costochondral joints [the joints between the ribs and breast-bone]. I diagnosed viral myalgia/arthralgia [muscular and joint pain]. He told me that he was taking Paracetamol which was not powerful enough. I advised him to continue his Paracetamol, but added Ibuprofen 400mg tid [three times a day] to his therapy. I gave him a prescription of 60 Ibuprofen tablets. Within half an hour of seeing me he telephoned the surgery and spoke to [the receptionist]. He explained to her that he wanted me to prescribe something else as he felt the Ibuprofen would not work. My receptionist advised him that I was still doing my surgery and advised him to phone back around 11.30 am, by which time I should have finished my surgery. Instead of phoning back [Mr A] returned to the surgery around 11.30 am. I invited him back into my consulting room. [Mr A] again said that he wanted me to prescribe something else. The Ibuprofen wouldn't work. He said that whenever he got a cold it went into his chest. I explained to him that I could not find any evidence of chest infection and that he did not need any drug other than Paracetamol that he was already taking and the Ibuprofen for which I issued a prescription.

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'[Mr A] was not prepared to accept my diagnosis which I arrived at after appropriate professional examination, nor was he prepared to accept my advice and recommendation. In the circumstances I felt that the doctor/patient relationship had broken down to such an extent that my only alternative was to suggest to [Mr A] that he register with a different doctor, in whom he might have more confidence. It is always regrettable when one reaches a decision, but I really felt I had no other option but to suggest this. The reason I did not prescribe a prescription for Paracetamol was that this is invariably cheaper to buy over the counter from the chemist. In the circumstances I felt I had no alternative but to contact the Health Board and request his removal from the list.

'B. Formal Response To The Complaint Set Out In The Statement Of Complaint '1) Complaint That GP Acted Inappropriately At The Consultation On 21 January

'At no time during the consultation on 21 January did I act in an unprofessional manner, nor was I rude to [Mr A]. [Mr A] was making an entirely unreasonable demand in insisting on the prescription of an antibiotic when in my professional opinion such treatment was not warranted. If I had infact [sic] acceded to his request I would have been acting unprofessionally. I did try to explain that I found no evidence of a chest infection, but he was not prepared to accept my diagnosis and in the circumstances I felt I had no alternative but to suggest to [Mr A] that he registers with a different doctor with whom he might have more confidence ... '2) Complaint That The Removal Of [Mr A] From My List Was Unreasonable

'I considered that the doctor/patient relationship had broken down to such an extent that my only alternative was to request his removal from my patient register. I felt that I had responded in a professional manner having taken a relevant history, reached the correct diagnosis and advised appropriate treatment for the patient. However [Mr A] was not prepared to follow my recommendation and wanted different medication even before he had tried my recommended treatment. The conclusion I reached was that [Mr A] did not trust my clinical judgement and therefore it was inappropriate to continue as his General Practitioner where our relationship had patently broke down.

'I did not take this step lightly and I have seldom done so in my thirteen years as General Practitioner (1993 = nil, 1994 = six, 1995 = two, 1996 = two, 1997 = two). I only do so when communications with the patient have irretrievably broken down and /or when the patient does not trust my clinical acumen and/or the patient does not follow my advice/ treatment...'.

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Short text of this investigation

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Last updated: 12 January 2006