Williamson, Andrea E.
Patients repeatedly removed from GP lists: a mixed methods study of "revolving door" patients in general practice.
PhD thesis, University of Glasgow.
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Introduction: Patients who have been repeatedly removed from General Practice (GP) lists, so-called “revolving door” patients in general practice have not been examined in the literature. This mixed methods study sought to define and characterise “revolving door” patients in general practice in Scotland. It investigated the impact they had on the NHS and the impact this status may have on “revolving door” patients themselves.
Methods: Thirteen semi-structured interviews with Practitioner Services and GP professional key informants and one “ex-revolving door” patient were conducted and analysed using a Charmazian grounded theory approach. Patient removal data from the Community Health Index were used to construct cohorts of “revolving door” patients and link them with routine NHS data on hospital admissions, outpatient attendances and drug misuse treatment episodes. These data were analysed quantitatively and qualitatively and all the data were integrated dialectically.
Results: “Revolving door” patients were removed four or more times from GP lists in six years. There was a dramatic decline in the number of “revolving door” patients in Scotland whilst the study was conducted. It appeared this was because the NHS response altered due to changes in approaches to treating problem drug use and pressure to reduce removal activity from professional bodies. The final influence was the positive, ethical, regulatory, and financial climate of the 2004 General Medical Services contract. “Revolving door” patients had three necessary characteristics: unreasonable expectations of what the National Health Service had to offer, inappropriate behaviour and unmet health needs. Problem substance use and psychiatric health problems were important. Professionals who came into contact with “revolving door” patients found it a difficult experience and they generated a lot of work. Being a “revolving door” patient impacted on the quality of care that patients received in general practice in terms of relational, informational and management continuity of care. “Revolving door” patients were more likely to be admitted to hospital after they have been removed from a GP list and more likely to be referred for addiction care after they were re-registered.
Conclusions: It was the status of being repeatedly removed from GP lists that set “revolving door” patients apart from the usual general practice population. I suggest that GPs were able to suspend their core values and remove “revolving door” patients because the legitimate work of general practice was challenged. There were two ways in which this may happen. The first was that “revolving door” patient’s dominant health needs were not viewed as biomedical because they contained aspects of a moral schema of understanding. The second was that their behaviour or expectations threatened the doctor-patient relationship. These were features common to other patients reviewed in the literature on problem doctor-patient relationships. “Revolving door” patients did not understand the unwritten rules of the doctor-patient relationship; so removing them from GP lists did not change their behaviour. Current theories about personality disorder and adult attachment should be integrated into the work of general practice and further researched in this context. This might help GPs and patients to improve problem doctor-patient relationships.
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