Advice: troubled or just troubling?

WHEN someone mentions the phrase “heartsink patient”, are there many among us who could not picture at least one or two people who fit that description?

These challenging patients present in a variety of ways and chances are they take up a disproportionate amount of your team’s time. This makes it an issue where the practice manager may need to get involved.

For many problems in general practice there are solutions that can be worked out pragmatically and implemented, such as with a system or process which needs “fixing”. This is far from the case when dealing with difficult patients. Each is unique and may be of any age, sex, background, education or class. It is also worth bearing in mind that someone who is regarded as one doctor’s heartsink, may not be another’s.

It is well established that a small proportion of patients can generate a disproportionate amount of work. In 2001 the BMJ published that the top 3% of attenders generate 17% of a GP’s clinical workload.

So how do you deal with these patients to minimise their impact on your GPs or GDPs?

Difficult patients may cause problems in many ways. They may be rude, unreasonable, demanding or aggressive. They may simply waste a huge amount of time by persistently not attending appointments. They may be suffering from some mental health problem or be in real pain, and this could affect their normal judgement. They may be dissatisfied or unhappy due to previous bad experiences and it might even come down to the patient just having a really bad day.

Whichever way these patients present they have an effect on the whole practice, so a team approach is required. Calling a meeting with all the GPs or GDPs to discuss these patients as they are identified can be a good place to start. Each difficult patient will need to be managed in an individual way to maximise the impact that might be made upon their behaviour.

Identifying the behaviours which the team agree are unacceptable is very important. Discuss a general approach to the patient taking into context their individual circumstances. You might decide to initially write to the patient, or it may be more effective or appropriate to ask the patient to come along to the practice and discuss their behaviour with the GP or dentist with whom they have had most contact and possibly yourself. But make sure that no one is left to deal with the patient on their own. It may be an idea to minute this discussion or produce action points, at least to begin with.

If this helps to change behaviours it may be all that the practice needs to do to effect change. If not then a series of meetings may be needed to ensure that the patient understands what is expected of them. Consider drawing up a behavioural contract to detail formally what behaviours will be acceptable to all parties. A contract will only be effective if it is signed up to – especially by the patient. PCOs often have designated groups to manage difficult patients. It may be well worth contacting your local group to get advice or support.

A few years ago one of my practices had significant interactions with a gentleman who not only was a frequent attender but was also having a fairly major impact on our out-of-hours service. We sat down as a practice along with our local pharmacist, community psychiatric nurse, out-of-hours service and a representative from our CHP. We drafted a contract and met with the patient to clarify all views and expectations. All services which this patient accessed then had a clear understanding of the issues, and were in effect "singing from the same hymn sheet". This did not allow the patient to play one service off another. The approach was initially very effective and did indeed change behaviour. However, it required quite a bit of monitoring to ensure that the contract was adhered to. It didn’t solve the issues for the practice but did make the situation more workable for the GPs, who are now much more comfortable dealing with this man.

Whichever way your practice decides to manage difficult patients it may only be effective if reviewed regularly. There’s a saying that you may not win every battle, just as long as you win the war. So there will be successes and failures.

Ultimately the patient relationship may deteriorate to such a significant degree that a practice may have to consider removing a patient from their list. This should be the last resort when all other options have been ineffective. Clear guidance on this process has been published by the General Medical Council in Good Medical Practice, and by the Royal College of General Practitioners in Removal of Patients from GPs’ Lists, which sets out the circumstances under which it is acceptable to remove a patient from your list. This can include a patient being violent towards you or your team, stealing from the premises or persistently acting inconsiderately or unreasonably. Similar guidance would apply to dental practices but check local regulations, especially with the recent introduction of continuous regulation for NHS patients in Scotland.

Whatever the reasons, the GMC is clear that “before you end a professional relationship with a patient you must be satisfied your decision is fair” and you must be prepared to justify that decision. However, with effective intervention, such a drastic step will hopefully not be necessary.

Aileen Wilson is editor of Practice Manager and has been a practice manager for 14 years. She is based in the north-east of Scotland