IT'S a fundamental principle enshrined in the NHS Constitution – the right to complain. Last year there were more than 162,000 written patient complaints against NHS services in England – an average of about 3,100 per week. Maybe not quite so significant when you consider that the NHS deals with over one million patients every 36 hours or about 4.6 million patients per week.
The NHS Choices website informs patients: “you have the right to complain, have your complaint investigated, and be given a full and prompt reply.” Not only this but patients have the right to expect that making a complaint will not prejudice their ongoing care.
But as any experienced clinician knows not all patient complaints are reasonable or rectifiable. Habitual or vexatious complainants can test the temper and sympathy of even the most patient doctor, dentist or practice manager.
In its complaints policy, NHS Scotland states that complainants may be considered to be habitual or vexatious if they display two or more of the following behaviours:
• Persist in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted.
• Change the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed.
• Are unwilling to accept documented evidence of treatment given as being factual.
• Do not clearly identify the precise issues which they wish to be investigated, despite reasonable efforts to help specify their concerns and/or where the concerns identified are not within the remit of the Health Authority to investigate.
• Focus on a trivial matter to an extent which is out of proportion to its significance and continue to focus on this point.
• Have threatened or used actual physical violence towards staff at any time.
• Have in the course of addressing a registered complaint had an excessive number of contacts with the Health Board placing unreasonable demands on staff.
• Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint.
• Are known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties involved.
• Display unreasonable demands or patient/complainant expectations and fail to accept that these may be unreasonable.
In dealing with such patients in primary care often the most immediate solution that occurs to practices is simply to deregister the patient. But this is a step that must not be taken without due consideration. A number of practices have ended up the subject of investigations by the ombudsman or the GMC/GDC for being too hasty in removing patients from practice lists.
This month the GMC published new guidance entitled Ending your professional relationship with a patient in which it states: "In Good Medical Practice we say: You should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient."
Such a breakdown might occur if a patient has been violent, threatening or abusive or has stolen from the premises or "persistently, acted inconsiderately or unreasonably". The guidance goes on to further advise that before ending a professional relationship with a patient, doctors should do what they can to restore that relationship and "explore alternatives".
One key principle in dealing with such situations is to separate an individual complaint or complaints from a pattern of "bad" behaviour in a patient. BMA guidance states: "It is a breakdown of the relationship rather than a complaint per se which must form the basis of any decision to remove a patient from the list."
Each complaint must be dealt with separately on its own merits and practices must ensure that complaints procedures have been correctly implemented. A common charge against doctors and dentists in such situations is that the patient has been victimised just because they complained. Remember that in dealing with vexatious patients it is the behaviour you are addressing. You are perfectly within your rights to challenge bad behaviour on the part of the patient and make clear what is and is not acceptable.
MDDUS advice in dealing with vexatious complainants is first to open a dialogue. Invite the patient to attend the practice for a discussion and try to get at the root of the problem. Sometimes there may be some underlying issue, such as a previous grievance. It may not even have to do with the patient themselves but with a family member. Some patients may also have unreal expectations of the service you are providing – for example that care should always be offered by a doctor rather than a practice nurse.
You should also consider the patient’s personal circumstances, bearing in mind any known physical or mental health conditions that may explain the reason for the difficult behaviour. Have they suffered a recent bereavement or job loss or marital breakdown?
To avoid charges of prejudicial treatment it is important to demonstrate you tried to mediate and resolve the breakdown in the relationship with the patient. There should be some discussion of possible ways of moving forward constructively and these discussions should be documented before making any decision to deregister.
Other alternatives to removal should be considered such as transferring the patient’s care to another partner (with the consent of both parties) or persuading the patient that it would be better for all concerned for he or she to attend another practice. In any case, regulations normally require that patients should be given a 12-month warning prior to removal, except in the case of violence or abusive behaviour in which removal can be immediate.
It would be wise to get some advice before considering the deregistration of any patient and remember that MDDUS advisers are on hand to discuss such matters.
ACTION Address both the behaviour and the individual complaint(s) when dealing with habitual or vexatious complainants. Consider deregistration only when all other alternatives have been exhausted.