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Supporting good practice

01 November 2003

Ms F, a 38-year-old professional, moved house and joined a new GP practice in the UK. She saw Dr A, who went through his usual booking history. He asked whether or not Ms F had ever used recreational drugs. She wasn’t happy with this question, seeing it as an insult. The rest of the appointment was spent addressing her discontent, with Dr A explaining it was an enquiry he made of all new patients.

A little while later Ms F attended for a smear result. She wanted to see the actual smear, and was aggressive when told this wasn’t practicable.

She had bowel and urinary symptoms and fertility concerns. Dr A arranged blood tests, a pelvic ultrasound and referred Ms F to a local gynaecology consultant.

Ms F was told her test results days after their receipt, in a telephone consultation with another partner, Dr L. Her bloods were normal and the scan showed fibroids. Dr L explained this and documented the conversation.

The next time Ms F was seen, she’d specifically booked an appointment with a female doctor, Dr G (the only one at the practice).

Unfortunately, Ms F was quite late and arrived after Dr G had finished surgery. This caused a scene in the practice reception, with Ms F shouting at reception staff, refusing to leave until Dr G saw her. Ms F was told that Dr G was otherwise engaged and was offered an alternative appointment.

She eventually accepted an offer from the practice manager for an appointment a week hence, earlier than the next available appointment with the in-demand female doctor. Ms F asked for the number of the health authority, making clear her intention to complain about events.

The reception staff were very upset by the incident.

The next time Ms F came to the surgery, she told Dr A that she didn’t trust the doctors at the practice.

After this, and upon hearing of the incident at the missed appointment, Dr A decided that the relationship between Ms F and the clinical and support staff had broken down irrevocably. He decided to have Ms F removed from his list and wrote to tell her this, explaining the reasons for the decision and providing details of how she could register with another GP practice.

Ms F didn’t take this well, requesting a meeting with the doctors and practice manager. This was arranged, with Ms F to be accompanied by a member of the Community Health Council.

The meeting wasn’t helpful. Ms F, aggressive throughout, said that she was being unfairly treated because of her colour and cultural background (Afro-Caribbean). This was a shock to all the staff, and the first time the issue had been raised. Dr A removed Ms F from his list.

Ms F complained to the local health authority, who convened an Independent Review Panel (IRP), to examine the allegations against the practice.

The practice team felt unfairly treated and marginalised by the process. An allegation that Ms F had been made to wait three weeks for test results was left as a matter for investigation, despite clear preliminary evidence from the medical records that this was not so.

An independent clinical assessor gave a report to the IRP which could find no fault with the medical treatment Ms F had received. This report was discounted by the IRP as it didn’t accord with their view.

The final IRP report largely upheld Ms F’s complaints against the medical (but not clerical) staff, including the accusation of racism. The practice felt that the IRP was not impartial and had reached conclusions based on conjecture and opinion, not facts.

Dr A contacted MPS for advice. Our medicolegal experts agreed that the IRP had incorrectly rejected the advice of a clinical assessor on grounds that ‘they are not in accordance with those of the panel’.

It seemed unusual for a lay panel to do this when considering clinical judgments. Our experts found many procedural and other irregularities in the IRP’s conduct of the investigation, final report and recommendations.

MPS helped Dr A with a submission to the Health Service Ombudsman. The ombudsman’s office investigated the IRP’s conduct. The report was supportive of the practice team and critical of the IRP. It made recommendations to the health authority on changing the training and duties of the IRP convener, to ensure future compliance with national directions and guidance.

Specifically, they noted, ‘The panel failed to take proper account of the evidence, including the advice of the clinical assessors; it exceeded its terms of reference and made flawed and inappropriate conclusions.’

The final paragraph of the report issued a formal apology from the health authority to the doctors at the practice; furthermore, the health authority agreed to fully implement the recommendations in the ombudsman’s report. The practice was exempted from following most of the recommendations of the IRP.

Learning points

  • Removal of patients from a GP’s list – Guidance on this can be found on the Royal College of General Practitioners’ website.
  • Health Service Ombudsman – In the ombudsman’s annual report for 2002-03 she said, ‘I continue to receive complaints about the way in which NHS staff handle complaints locally... The failure of some NHS bodies to reach a reasonable standard in this area is unacceptable.’ The report includes another example of an unsatisfactory Independent Review.
  • Discretion – The GPs had followed good practice – well-documented procedures and clear, accurate records. This made it easier for MPS to support their appeal to the ombudsman.