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.

The MDU receives around 400 calls a year to the advisory helpline from members asking how to manage difficult patients. The vast majority came from general practice.

Removing a challenging patient from the practice list isn't always warranted or viable. An alternative strategy is the use of behaviour contracts between the practice and the patient.

Sometimes called doctor-patient contracts or acceptable behaviour contracts, their objectives are broadly the same:

• to outline to the patient what aspects of their behaviour are inappropriate
• the impact this has on others
• how it can interfere with the effective delivery of healthcare
• the potential outcomes if their behaviour does not change.

NHS Protect, in its 2012 publication Unacceptable Behaviour - guidance on warning letters and other written communications, outlined strategies for addressing this type of behaviour. The guidance describes the types of behaviour that may be regarded as unacceptable and various ways in which these can be addressed, including Acceptable Behaviour Agreements (ABAs).

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.

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.