The contract should be viewed as a useful tool in rescuing a deteriorating professional relationship before it becomes unsalvageable, rather than as a punitive measure. The MDU advises using ABAs only in cases of persistent bad behaviour that would inevitably lead to a breakdown in the doctor-patient relationship and removal from the practice list.
Involving the patient
Behaviour contracts are more likely to be successful if the patient is involved in drafting it, as a sense of ownership of the contract may translate to a sense of responsibility in implementing it.
Patients may be more receptive to the contract if it does not focus solely on what is expected of them but also explains what they can expect of the service provider in return.
Similarly, the use of positive language can also increase the likelihood of an ABA being successful. By stating what the patient should do - for example, 'treat staff with respect' - rather than what they should not - for example, 'not swear, shout or insult staff' - the patient may be more amenable to the request. There will, however, be cases where it is necessary to be explicit about what behaviour will not be tolerated so the patient is clear about what is required of them.
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The MDU highlights other factors that should be considered when using behaviour contracts:
- Consider if the patient's behaviour is related to any underlying medical condition which requires treating first.
- Ensure that the patient has the capacity to understand what they are agreeing to when asking them to co-sign an ABA.
- Be aware that when signing an ABA you will need to be satisfied that the use of such a document will not prevent the provision of necessary healthcare to the patient.
- You must adhere to GMC 'Good medical practice' (2013), paragraph 71, which requires you to be honest and trustworthy in signing documents and take reasonable steps to ensure what you are signing is correct.
The contract should be viewed as a useful tool in rescuing a deteriorating professional relationship before it becomes unsalvageable, rather than as a punitive measure
Of course, there will be situations where the use of behaviour agreements will be inappropriate, for example when patients have demonstrated extremely violent behaviour, and their immediate removal is necessary to protect staff and other service users from harm.
Also, while in an ideal world patients would wish to engage in such processes, in reality they may either refuse to be party to the agreement or, despite signing one, their behaviour will continue or only temporarily improve before relapsing. In such cases the patient may need to be removed from the practice list. However, this decision should only be taken as a last resort and the practice must adhere to the formal removal process.
The MDU would like to thank John Thomson, Senior Legal Case Officer, LPU and the team at the NHS Protect Press Office for their help in researching this article.
Dr Ellie Mein
Medico-legal adviser
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
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