Patient's response to the research

In a society where responsible people do not seek to burden their doctors with trivial matters—and, indeed, endeavour to treat themselves—there may well be a modicum of malingerers whose time-wasting activities must be addressed.

The research echoes many conversations with patients during my 40 years in the nursing profession and, recently, eight years serving Lichfield community health council. Those conversations revealed the depth of feelings of anger, concern, fear, and frustration following the apparently mandatory removal from their GP's list.

Some patients felt that they had been reduced to the status of second class citizens and simply had no redress in a situation over which they had no control, no information as to their alternatives, and fear they had been labelled as a “difficult” patient by a new doctor. The patient advisory liaison service (PALS) system, where the practice receives and reviews patients' complaints, may well deepen suspicion and, far from alleviating patients' fears, may well aggravate the situation in which patients find themselves.

Despite the new concept of public involvement in the modern health service, the divide between doctor and patient still seems to exist. The research shows that there have always been unwritten rules of behaviour on both sides. The doctor may feel that those rules have been broken, but the patient fails to understand why such drastic action has been taken.

The process of removal cuts the patient adrift, and there ought to be an intermediary equipped to explain the seriousness of the situation to both patient and doctor. Also, the practice of an arbitrary notification signed by someone in the system should cease.

The research brings into the conscious arena the unspoken and unwritten rules which underpin general practitioners' practice. These rules are known to the practice but, sadly, in most cases they are not known to the patient.

Patients must be included in the process before removal. The research shows the emotional experiences of the patients in a sympathetic way, and also how difficult some of the complex issues involved can be.

This research ought to be used in both medical and nursing education to teach about relationships and their possible breakdown.

When patients' forums are formed in the future, this will represent excellent research for discussion. The newly formed health and overview scrutiny committees ought to be interested in using this as a local authority discussion document.