A GP received a phone call from the local university asking for clarification on a letter they'd received. The caller explained that the letter was signed by the GP and appeared to be in support of a student being allowed an extension on their coursework deadline due to ill health.
The GP didn't recall signing the letter and didn't recognise the circumstances described or the patient's name. As such, the GP explained she would need the university to send through a copy of the letter to review before she could comment on it.
After looking at the copy, the GP found that the details of the student did match a patient on the practice's register, but a review of the notes showed they hadn't been seen for at least two years. The letter was written on paper with the practice letter head on it and a signature that was similar, but not identical, to the GP's.
The GP called the MDU advice line to ask what she could do next.
We continue to receive variations on this query, which can range from forged prescriptions and genuine sick notes that have been altered to prolong the duration of the patient's sick leave, through to more elaborate letters that have been created entirely from scratch.
With editing software freely available it has become increasingly easy to make a convincing copy of a practice's headed notepaper. There are even various sites online that offer advice on how to convincingly forge a sick note or that allow you to buy replica NHS sick notes.
In situations such as this the MDU advises that it's not a breach of confidentiality if you simply confirm that you didn't create the document, or that any altered documents aren't as they were when you originally signed them. However, no other information should be given about whether the patient is actually registered at the practice or if any of the medical information is correct.
When faced with seemingly fraudulent documents doctors often feel understandably aggrieved and ask if they should involve the police or remove the patient from the practice list. But although you might be left feeling that there's been a breach of trust, removing the patient from the list without a prior warning could leave the practice vulnerable to criticism.
The letter of the law
The General Medical Services contract suggests that doctors can remove a patient from their list if they have reasonable grounds. However, except in specific circumstances, it is expected that the patient would have been given a warning in the preceding 12 months explaining they are at risk of removal and why. The contractor would need to be able to justify such a decision. A patient can also be removed from a list with immediate effect if they have been violent and the incident has been reported to the police.
It is also helpful to consider the GMC's guidance 'Ending your professional relationship with a patient' (2013), which indicates some examples of how the relationship with a patient may break down, including if the patient has 'persistently acted inconsiderately or unreasonably'. However the guidance also advises that doctors should not only have warned the patient but done what they can to restore the relationship and explored alternatives to ending it, which should be a last resort.
Bearing this guidance in mind, it is often helpful to ask the patient in to discuss the letter or form in question and to make a judgment after that discussion as to the best way forward.
Removing the patient from the list without a prior warning could leave the practice vulnerable to criticism.
In situations such as this, where there is no legal obligation to disclose the patient's actions and where patient consent to do so would be unlikely to be forthcoming, you would need to consider whether disclosure could be justified in the public interest. This decision is essentially a balancing act between the benefits to an individual or society of disclosing versus the harms of disclosure.
Disclosure in the public interest without consent, or after refusal of consent, may be justified if failure to make the disclosure could expose others to a risk of serious harm or death. This could arise where disclosure might assist in the prevention, detection or prosecution of a serious crime, as outlined in paragraphs 51-56 of the GMC's 'Confidentiality' guidance (2009).
This guidance does not provide a specific definition of 'serious crime', but on page 35 of the Department of Health guidance 'Confidentiality: NHS Code of Practice' (2003) the examples listed are murder, manslaughter, rape, child abuse, substantial financial gain/loss and risk of state security/public order. Theft, fraud and property damage where loss would be less substantial are not thought to constitute a serious crime.
The GP was given the above guidance by the MDU's medico-legal adviser and decided to invite the patient in for a meeting. A few weeks later the GP called the MDU back to explain that the patient had admitted they'd written the letter, having copied it off a genuine practice letter received by their mother, who also happened to be a patient with the practice. The patient had also confessed that they had copied the GP's signature from the same letter.
As the patient had been apologetic and had agreed that their behaviour was unacceptable, the GP had decided not to send a warning letter on this occasion, but was still concerned about whether this incident should still be reported to the police as attempted fraud.
However, after the MDU's medico-legal adviser explained the legal position on disclosure in the public interest, the GP concluded that the patient's fraudulent letter didn't constitute a serious crime and decided not to pursue a criminal prosecution any further.