How manage a disruptive patient

Dealing with a disruptive patient can be one of the most challenging aspects of general
practice. Senior Medicolegal Adviser Dr Richard Stacey provides advice on the best way
to manage such a situation.

At the end of a busy Monday morning surgery at the Sunshine Practice, Dr Duncan was asked by the practice manager if she would mind speaking with one of the receptionists (Sarah) who was upset as a consequence of an altercation with a patient at the reception desk. The patient had brought a repeat prescription request and had insisted that it should be processed immediately. Sarah had explained that all the GPs were currently in surgery and that the practice policy was that 24 hours’ notice was required for all repeat prescription requests. The patient was unhappy with this explanation, raised his voice and (in front of a busy waiting room) said, “the policy is useless, the practice is useless and you are completely useless!”. The patient then stormed out of the practice leaving Sarah in tears.

What are the immediate issues?

The immediate priority is to speak with Sarah in a protected setting in order to provide her with support and to seek an understanding as to what happened.

In order to investigate and corroborate the events, it would be helpful to seek a written statement from Sarah, together with any of her colleagues that witnessed the incident.

In light of the undoubted upset this has caused to Sarah, it is important to offer her the requisite support.

Irrespective of the fact that the patient’s behaviour has been unacceptable, the following matters should be taken into consideration:

• The repeat prescription request will require processing
• There may be an underlying reason why the patient requested the repeat prescription as a matter of urgency
• The patient’s behaviour may have been a manifestation of an underlying mental health problem and/or there may be mitigating personal/social circumstances. 

In light of these matters, it is important to make contact with the patient in order to highlight the distress that their behaviour has caused, to clarify the position in relation to the provision of the prescription and to seek an understanding of any underlying issues.

Please refer to Box A for tips in relation to approaching the patient.

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Box A - Approaching the patient

• The thought of approaching a patient in such circumstances is undoubtedly anxiety-provoking
• It is important that the approach is made at the earliest opportunity (but not before a full understanding of the incident has been reached)
• The approach should be made by the most appropriate person (for example; one of the GPs or the practice manager)
• Protected time should be set aside
• A contemporaneous note should be made of the conversation with the patient
• Sometimes, the conversation with the patient can be cathartic and the patient may accept that their behaviour was inappropriate and offer an apology
• Conversely, the patient may dispute the allegations and take a confrontational approach

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Can the practice remove the patient from the list?

It is entirely understandable that, for a variety of reasons, one of the first considerations is as to whether or not to remove the patient from the list.

The National Health Service (Primary Medical Services) Regulations (2004 - as amended) set out the provisions for the removal of patients from the practice list and there is provision for removing patients who are violent to staff members (or who are threatening to the point at which they feared for their personal safety) with the following caveats:

• There is no obligation to provide the patient with a warning
• Removal takes effect after the practice notifies the NHS England Area Team or the
• Health Board (in Scotland, Wales and Northern Ireland) of a request for immediate removal
• The notification must be followed up in writing within seven days
• The incident must be reported to the police immediately
• The patient should be informed of the reasons for the removal unless:
  • It would be harmful to the physical or mental health of the patient to do so
  • It would put practice staff or patients at risk
  • It would not be reasonably practical to do so.

In the circumstances of this case, Sarah did not feel that her physical safety was at risk hence the criteria for immediate removal from the practice list are not met. The practice will therefore need to consider providing the patient with a written warning about their behaviour (except for the circumstances set out in Box B, a patient can only be removed from the practice list if they have been provided with a written warning within the preceding 12 months)

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Box B - A patient cam be removed without a warning if:

• They have been violent towards a staff member (or threatening to the extent that the staff member feared for their personal safety)
• They have moved outside the practice area
• There are reasonable grounds to believe that issuing a warning would be harmful to the patient’s physical or mental health
• It is not reasonable or practicable for a warning to be given.

The provision of a warning is a potentially emotive issue and might prompt the patient to dispute the suggestion that their behaviour was unacceptable. That said, it is important to put down a marker in relation to the patient’s behaviour and to put them on notice that if there is a repeat of the behaviour it will put their ongoing registration as a patient of the practice in jeopardy.

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A sample warning letter is set out at Box C

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Box C - Sample warning letter

Dear [name of patient]

I am writing further to the incident at the reception desk on 1 February 2016 and your subsequent telephone conversation with Dr Duncan.

I understand that Dr Duncan has managed to resolve the issues relating to the provision of your repeat prescription.

I was sorry to hear that you were frustrated that it was not possible to process your repeat prescription request immediately and I remind you that we ask for 24 hours’ notice for the provision of repeat prescription. I have attached a copy of the practice repeat prescription policy for your reference.

Unfortunately, your frustration was reflected in your interaction with a member of our reception staff who was intimidated by your approach and this in turn caused her some considerable distress.

I understand that it is possible that you may not have realised the impact that your approach has had on the member of the reception staff, however I am obliged to inform you that if there is a repeat incident of this (or a similar) nature then consideration will be given as to whether or not you should remain on our practice list.

I am sorry to write in these terms and I sincerely hope that this marks an end to this unfortunate matter.

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The letter may lead to one of the following outcomes:

• The patient may dispute the suggestion that their behaviour was unacceptable, in which case the statements prepared by Sarah and the other witnesses will be helpful in responding to any such suggestion.
• The patient may demonstrate a repeat of the behaviour, in which case the practice will be well-placed to remove them from the practice list in accordance with the relevant regulations (if the behaviour is repeated within 12 months of the warning). 
• The patient may modify their behaviour, which would be the best outcome for all parties.