Sometimes called doctor-patient contracts or acceptable behavioural contracts, their objectives are broadly the same: the MDU highlights other factors to be taken into account in the use of behavioural contracts: while patients in an ideal world wish to carry out such processes, they may actually refuse to participate in the agreement or, although they sign one, their behaviour continues or only improves temporarily before reoffending. In such cases, the patient may be removed from the list of practitioners. However, this decision should only be made as a last resort and practice must be kept within the formal withdrawal process. The treaty should be seen as a useful tool to save a deteriorating professional relationship, before it can be saved, as a punishment. The MDU advises the use of ABAs only in cases of persistent misconduct, which would inevitably lead to a breakdown of the doctor-patient relationship and the removal of the list of practitioners. Of course, there will be situations where the application of behavioural agreements will be inappropriate, for example when patients have engaged in extremely violent behaviour, and their immediate removal is necessary to protect employees and other service users from harm. NHS Protect described strategies to combat this type of behaviour in its publication Unacceptable Behaviour – Guidance on Warning Letters and other written communications, published in 2012. The guidelines describe behaviours that may be considered unacceptable and in different ways of addressing them, including Acceptable Behaviour Agreements (AAAs). Removing a demanding patient from the practice list is not always justified or feasible.
Another strategy is to apply behavioural contracts between practice and patient. Similarly, the use of positive language may increase the likelihood of success of an ABA. By explaining what the patient should do – for example, “treating staff with respect” – and not what they should not do – for example, “do not swear, shout or insult staff” – the patient may be more supportive of the request.