Should doctors sack their patients?

The GP-patient relationship is more important than a patient's right to stay with a doctor, says Simon Fradd

Much concern has been expressed about the number of patients removed from doctors' lists. The figure commonly quoted for last year is 85,000. Whether or not the figure is correct, the bulk of removals are made because the patient has moved out of his or her doctor's practice area.

The British Medical Association has been working with the Patients' Association over the past 18 months on many issues of common interest concerning the doctor-patient relationship. Both bodies agree that there is a need to preserve the GP's right to remove patients. Indeed, the act of such removal can benefit the other patients, as well as the individual being removed. Patients often become attached to their family doctor. It is a credit to the relationship that they should do. When then move, the patient will often be prepared to make heroic efforts to travel back to the surgery. They will do almost anything rather than start afresh with a new GP.

I have had many such patients pleading with me not to put their new addresses on their medical records, to avoid the need to be taken off my list. In these circumstances I am just as sorry as the patient to see them go. The doctor, however, has an ethical duty to the patient. The time will come when a patient cannot travel to the surgery and needs help quickly. It is the doctor's responsibility to make sure that they are able to meet their obligations in these circumstances, not only to the individual patient but also to the others on their list.

To argue that there are no circumstances that justify the removal of the patient by the doctor is to fail to understand the patient-doctor relationship. This must be based on mutual trust. And thus, when this trust has been breached, it may well be impossible for the doctor to rebuild it in order to effectively care for the individual patient.

This is why only last year the Health Secretary agreed that patients who had threatened or carried out violence against their GP, or his or her staff, could be removed forthwith. Once a doctor has been attacked by a patient, it is reasonable to assume that in trying to continue to look after that individual, he or she might be somewhat mentally distracted from giving individual attention to the patient's clinical problem. It is only fair that even a patient who has been violent should receive the full attention of their personal doctor. Therefore, it is in their interests to change doctors.

As employers, we also have a responsibility to our staff. We accept a certain level of risk in our own profession, but this does not extend to our staff. When they have been threatened or attacked, they have the right to our full protection.

There is, however, an overriding caveat: removal should not be for the convenience or self-interest of the doctor. Thus, they should not remove patients because their medical condition means they need more care than the average, or because their care is expensive; nor is there any evidence that this ever happens.

A doctor's duty may sometimes be to balance the interests of the individual patient against those of others, but it is always to put patients' interests above their own.

The BMA's guidelines state that it is good practice both to tell a patient that he or she is to be removed from a list and to inform them of the reasons why. Some argue that the reasons should be given to the health authority as well. Unfortunately, this breaks our duty of confidentiality. The net effect has been further to complicate the issue of researching patient removals. Health authorities record the reason for removals as either "those where the patient has moved" or "other". We have been working with the Patients' Association to see how we might analyse the data in greater detail.

All surveys support the fact that the bulk of patients have an excellent and stable relationship with their doctors. The number of patients removed is fewer than three per GP per year, and most of these cases the patient has moved. To force doctors to stay with patients where they feel the relationship has broken down would be as illogical as removing the patient's freedom of choice.

I can understand anyone having a sense of hurt and anger when they feel they have been unjustly removed. However, it is not the right to insist on staying with a doctor that has any intrinsic value, but a good-quality relationship with a caring doctor. If I found myself being removed from a doctor's list without just cause, I would feel the doctor's loss was far greater than mine.

The writer is a GP in Nottingham and a GP negotiator for the BMA.