Removing Patients from GP Practice Lists at the Contractor’s Request
Acknowledgement and thanks to Dr Julius Parker, Chief Executive, Surrey & Sussex LMCs for allowing us to share information from their website.
Deciding to remove a patient from a practice list is normally the action of last resort for most General Practitioners and these cases need to be handled very carefully. It can be an upsetting experience for all involved, and may have significant implications, both for the patient and the practice. It is important for all practices to have a policy in place for this process, and for all practice staff and doctors to be aware of and follow the practice guidance carefully. Although there is no formal Appeal process, such a decision may generate a complaint and cause widespread adverse publicity.
There are often complex issues leading to a patient’s behaviour and while it is never acceptable for staff to feel threatened, every effort needs to be made to ensure that due process is followed in order that you are not in breach of your GMS/PMS contract.
When considering an irrevocable breakdown you may wish to read the GMC guidance on ” Ending your professional relationship with a patient “.
A written warning needs to be issued advising the patient that their behaviour is unacceptable and that if any further incidents occur, they may be removed from the list. Click here to access our zero-tolerance pack which includes example template letters.
Please click here to download an example of an agreement/covering letter which a practice may wish to adapt for patients whose behaviour is inappropriate but not violent.
Violence or threatening behavior by the patient is a special case. It usually implies a total abrogation by the patient of any responsibility towards the doctor or other members of the practice and will normally result in removal from the list. As well as having a right to protect themselves GPs have a duty as employers to protect their staff and as providers of a public service those with reason to be on their premises.
Practices should also note that as part of a CQC Inspection, or Healthwatch visit, practices will be expected to demonstrate they have a policy in place and that General Practitioners and Practice Managers can demonstrate they use this policy when making such decisions.
The importance of this issue is reflected in the amount of professional advice available; examples are listed at the end of this document and the LMC recommends practice policies explicitly refer to one or more of these guidance documents, or to this LMC guidance. The Parliamentary and Health Service Ombudsman has highlighted concerns about this issue on several occasions in recent years.
The relevant GMS contractual terms are within Standard GMS Contract Nov 22. PMS contracts have the same provisions. Para. 13.10 (Removal from the list at the request of the Contractor), Para. 13.11 (Removals from the list of patients who are violent), Para.13.13 (Removals from the list of patients who have moved) and Para 13.14 (Removals from the list of patients absent from the UK etc)
Under Para 13.10 General Practitioners should:
- Not remove a patient for discriminatory reasons; in addition, the LMC recommends that every effort is made not to remove patients if the practice has received a complaint from that patient or until the process of resolving it is complete.
- Give a reason for the decision to remove, however, if a more specific reason cannot be given it is acceptable for the reason given to be that there has been an irrevocable breakdown in the relationship between the patient and the doctor.
- Give the patient a warning that they are at risk of removal, and why. Normally a patient should not be removed unless they have received such a warning over the previous twelve months.
Exceptions to this are if the GP has reasonable grounds for believing such a warning would:
- Cause harm to the patient’s physical or mental health
- Put at risk a member of the practice.
General Practitioners need to keep a written record of:
- Any warning given to patients, and the reason(s) a warning was given
- Why a warning would have been given, but was not (as this provides a record which may be used if a patient is subsequently removed)
- When a patient is removed, and the reason(s) given for this.
NHS England (or a Level III, delegated, co-commissioning ICB) is entitled to inspect these records on request.
Para. 13.11 refers to patients who are violent or whose behaviour means others (essentially practice staff or other patients) fear for their safety. In such cases, providing the practice reports the incident to the police, a patient can be removed with immediate effect. When the practice formally reports an incident to the local Police, they will be given an Incident Number, which should be retained within the record of the deregistration process.
Patients should also be informed of this decision, though not if this is impractical to do, or if doing so may cause harm to the patient’s physical or mental health or place at risk a member of the practice staff or a doctor.
GPs should also note in a patient’s medical records if they have been removed from the practice list under this paragraph and the reason(s) why this decision was taken, but only in factual terms, no opinions should be entered.
Aside from the situation of unanticipated violence or abuse, the LMC recommends all practices adopt a step-by-step approach in considering whether a patient should be removed. It is professionally important to consider whether inadequate communication is in fact the problem, as studies have shown most patients who have been removed from practices say they did not understand why the decision had been taken. Practices should therefore: –
- Ensure all incidents that might lead to a warning or removal are identified
- Discuss these incidents and inform appropriate clinicians and other practice staff, such as receptionists
- Ensure all staff and doctors are aware of the relevant practice policy
- Consider whether any aspect of practice organisation or clinical care could have contributed to the incident and could be remedied.
- Consider informing the patient, but when doing so, also suggesting ways in which the patient’s behaviour or actions may be altered and thereby do not create the difficulties that the practice is describing.
- Consider an informal discussion, or meeting, prior to a written warning.
- Try to encourage the patient to understand the nature of the problem and also be prepared to listen to the patient’s perspective.
In this way both the practice and patient have an opportunity of resolving the apparent difficulties, which may have added benefits in terms of improving the doctor/patient relationship. If, however, it is impossible to achieve a successful outcome all involved will know they have tried to do so, and practice staff and doctors cannot subsequently be appropriately challenged or accused of making hasty or ill-considered decisions.
If a patient is removed, the removal letter should, as well as explaining the decision, also include:
- A reassurance that the patient will not be left without NHS care, and that they can register with another practice.
- Advice on where help can be obtained (normally from NHS England or the ICB) in terms of registration.
- An explanation (if relevant) that this decision does not apply to other members of the patient’s family. Although there may be occasional circumstances when this is justified, particularly if a patient is being removed under Para 21 and they are a parent or carer who can be expected to be present when their relative needs to see a doctor, normally when a patient is removed other members of a family should not be simultaneously removed. They may be entirely unaware of their family member’s behaviour, or, in the case of children, not in a position to influence it. En bloc removal of patients who have not been warned of such a risk or who have not engaged in actions that may justify removal can create particularly adverse publicity (if, for example, the local MP or the Ombudsman is contacted) and a complaint which may prove difficult to justify.
It is important in any communication with patients to remain entirely factual and polite.
Removal of patient from practice list – process flowcharts:
|8 – Day Removal
|30 – Day Removal (Patient moved OOA)
|30 – Day Removal (Patient Absent from UK)
The GMC provides guidance based around GMC Good Medical Practice, which is helpful for GP colleagues wanting a professional rather than regulatory view: Ending your professional relationship with a patient – ethical guidance summary – GMC (gmc-uk.org)
The Ombudsman has commented on this issue a number of times, including: Decisions – Parliamentary and Health Service Ombudsman
The MPS guidance is below, although the other Indemnifying Organisations also offer advice: