Getting removed from your GP’s list normally requires significant incident or aggressive behaviour or language. However, newly amended guidance now includes ‘persistent or unrealistic service demands’ as a potential reason to deregister patients.

NHS England’s guidance reiterates that removing patients for these reasons is ‘expected to be an exceptional event’, but the vague language surrounding what would be fair grounds for deregistration has been far from ideal for anxious patients.

What constitutes ‘unrealistic’?

The lack of clarity regarding what constitutes ‘persistent or unrealistic service demands’ has caused worry among some patient communities, especially those managing long term or complex conditions.

Distilled Post spoke with “Kirsty” about how this new change has affected her mental health. ‘With how often they have to speak to me I’m worried they’re going to kick me out,’ she said. Kirsty regularly seeks support with her anxiety, needing repeat doctor’s notes and multiple appointments to find suitable medications. ‘People with chronic health problems need more help; most of the support we need could be considered reasonable, but the “persistent” caveat is concerning.’

‘I know the NHS just wants to make GP’s lives easier, especially with so many GPs leaving, but getting rid of “difficult” patients is not the answer.’

NHS staff have been increasingly faced with violence and harassment since the start of the pandemic, so a change in the rules that allow them to deregister patients is not entirely unexpected. GPs are under a lot of general strain on top of these major incidents, making steps to support and protect them in their workplace absolutely essential.

However, we must ensure this does not come at the detriment of general patient wellbeing; this can be achieved with something as simple as reassuring concerned patients that they will not be penalised for regularly calling their practice.

Most GP practices have a zero-tolerance policy regarding physical or verbal harassment of staff, but this new change may enable GPs to deregister problematic patients before things escalate to this stage. Modality – a primary care Super Partnership serving 450,000 patients – has run several zero-tolerance units for patients who may not be welcome on GP lists to ensure these patients do not fall through the cracks.

Persistent demands

Seeking support with complex or chronic conditions, especially those that aren’t visible, is already mired with medical staff not taking you seriously. Some patients are concerned that this new guidance will make things worse.

Getting a diagnosis for conditions such as Fibromyalgia takes a huge amount of chasing GPs. The journey to diagnosis is often tough for complex and tricky to diagnose conditions, and patients often have to spend many months providing evidence of their condition to their doctors. Persistence is precisely what is required for these patients to receive the support and care they need, making some patients anxious about seeking diagnoses or ongoing support from their GP in fear of being deregistered or otherwise having their experience dismissed.

While it is unlikely that patients will be deregistered for regularly seeking ongoing and appropriate support, more clarity on what qualifies as ‘persistent and unrealistic’ would help put their minds at rest.

Mind the gap

The difference between patient expectations and what is realistically possible in a single appointment is sometimes vast. This is often through no fault of the patient but can result in them feeling disappointed with what the GP was able to offer.

Unrealistic expectations of staff productivity from management also carries substantial risk to patient safety; if staff are rushed and pressured they may feel the need to cut corners or simply skim read things that require their full attention, sacrificing safety for the sake of speed. Over time, overburdening staff with impossible targets can lead compliance with safety protocols to slide.

Patients may feel like appointments are rushed or like the GP doesn’t have time to truly listen to their concerns or the details of their conditions. Sadly, if managerial expectations are too high, this can be the case.

While long wait times (in terms of booking appointments and in terms of waits on the day) and short appointments can be frustrating for patients, it is essential that these facts are clearly communicated. For example, if patients are made aware that their GP is running an hour behind when they arrive at the practice, they will be far less frustrated when the appointment actually takes place as they have been able to manage their expectations accordingly.

Practices should also make it clear what it is possible to achieve in a single appointment slot and advise patients to book additional appointments (back to back or separately) for additional concerns. This will help manage waits for others and also ensure patients do not feel rushed or disappointed in what their GP could get through in the allocated time. To help streamline this, practices should take steps to ensure patients feel comfortable speaking to receptionists about the reasons for their appointments so that the appropriate time slots can be booked.

Without clarity on what it is actually possible for a GP to achieve, patients may simply not be aware that their service demands are ‘unrealistic’.