Removal from a GP's list: qualitative research is needed

Editor—Pickin et al offer a postal questionnaire survey of general practitioners' reasons for removing patients from their lists.¹ To date, published research on removals has relied on an analysis of routinely collected health authority data that do not allow the reasons for removal to be ascertained except for immediate removals on the grounds of violence.²,³

We think, however, that there are important problems with the methods adopted by Pickin et al. They base their list of possible reasons for removal on two postal surveys of general practitioners, one of which is unpublished and has a response rate of less than 30%.⁴ These studies may have inappropriately limited the number, range, and type of reasons under investigation. Moreover, respondents may be especially prone to giving publicly acceptable reasons for removal in this kind of questionnaire survey, as Pickin et al themselves acknowledge.

We argue that removal and the reasons underlying it remain poorly understood phenomena which require good quality qualitative research to address them. We have begun this process by undertaking an in depth interview study of general practitioners' accounts of removing patients and patients' accounts of being removed from a general practitioner's list. Our preliminary findings support the conclusion by Pickin et al that there is little evidence that patients are removed on economic grounds.

We think, however, that Pickin et al have presented an overly simplified view of what is an extremely complex and stressful process, which has profound implications for our understanding of the relationship between doctor and patient and how it should be managed. For example, the issue of formal and informal practice policies on removal are absent from the study by Pickin et al, as is the role of relationships between the patient and other practice staff such as receptionists. Perhaps, most importantly, Pickin et al do not consider the concept of the “difficult” patient in general practice and the important notion of a breakdown in the relationship between doctor and patient, which is found in published guidance on removal.⁵

Future studies of patient removal should be more soundly based on detailed qualitative investigations to inform the content and design of instruments so that they add to our understanding of this important primary care issue.