Should doctors sack their patients?

Some GPs strike off patients unfairly, but blame the reforms that turned patients into commodities, says Stephen Amiel

For doctors, putting a patient off your list couldn't be easier. All you do is write to your Family Health Services Authority and say, "Please remove Mr So-and-so from my list immediately." No reason has to be given, you don't have to say or write a word to the patient and, after a statutory few days' stay of execution with no right of appeal, the job is done.

Similarly, a doctor can refuse to take a patient on to his or her list, more or less without giving a reason.

Even if a patient is forcibly allocated to a GP, he or she can be moved on elsewhere within a month or two.

One or two GPs might condone a colleague striking off an elderly patient because her house smelled of tobacco - as was the case reported in yesterday's newspapers. A few might approve, but consider him foolish for giving a reason at all. Quite a few might think they wouldn't have too many patients left if they struck off everyone whose feet smelled, or whose sexual proclivities they disapproved of, or who - worst sin of all - didn't do what their doctor said. But most of us would defend our right, and our patients' right, to terminate, without having to give reasons, a relationship that had irretrievably broken down.

I've heard a few stories like that of the GP above in my 15 years in the job, but mercifully few. More worrying for me are the stories, now increasingly common, of GPs striking patients off their lists because they generate too much work, because they prevent target payments being achieved, or because they drain a prescribing or hospital referral budget too much.

Yes, I know of a GP years ago who removed all patients from his list whose notes were more than an inch thick (I know, because he sent them to register with us!). But we are now reaping the harvest sown by those NHS reforms of 1990. Heralded as "putting patients first", these so-called reforms have turned patients into commodities and many GPs into largely unwilling players in an alien marketplace.

On the one hand, Patient's Charters tells patients what they should expect from doctors and tell them how easy it is to change doctors if they don't like the service they are getting.

GPs, on the other hand, are now forced to see patients as assets or liabilities. The young, fit, articulate, educated, mobile patient will, particularly if he has private medical insurance, drain the GP fundholder's budget very little. The elderly patient on several expensive drugs, the HIV-positive drug addict, the chronic schizophrenic, will cost the GP, already burdened by huge increases in paperwork, increased out-of-hours demand and so on, both time and money.

It is hardly surprising, although no less indefensible, that some GPs resort to putting such patients off their lists on flimsy pretexts, and others find similarly flimsy pretexts for not taking them on in the first place. That such stories are still only anecdotal gives much credit to my colleagues, and none at all to the Government.

Most GPs, especially those working in inner cities, will have experienced threats or actual violence from patients within the past year. This remains overwhelmingly the most common reason for a GP to strike off a patient.

As seems to be the case with the beleaguered Swansea GP who put 200 of her patients off her list in six months, drugs may often be the underlying reason for this violence.

There is no doubt that some drug-dependent patients can place an intolerable strain on any GP practice. It is a sad fact that the GP services available in the most deprived areas of our cities are often isolated, run-down and ill-equipped, without the space for support staff, visiting drug rehabilitation workers and so on.

It would be nice to think that all a GP has to do in this situation is to extend to every patient what is, in my view, the basic right of everyone: a relationship with their doctor based on mutual regard, responsibility and respect. This seems a pious hope for such as my colleague in West Glamorgan.

The people living in such areas are victims themselves, of unemployment, poor housing, social alienation and hopelessness. Abuse of their GP service, like the vandalism of their estate, is both a symptom of deprivation and a cause of further deprivation. Denying them access to health care will achieve nothing, but who can blame the GP involved? Until the root causes are dealt with, alternative methods of delivering health care will be needed, which combine access to health care for the patient with security for the doctor.

Turning GP surgeries into fortresses won't work, and no GP would willingly work in one either. Seeing patients in police stations is demeaning for all concerned. GPs working in a primary care facility within an accident and emergency department, with adequate security presence, may have to be tried. Otherwise drug users, the violent mentally ill patient and other of society's outcasts will become even more of a danger to the GP, the public and themselves.

The writer is a GP in inner London. He represents local GP opinion as vice-chairman of his Local Medical Committee.