More than half of UK practices have removed patients from their practice list in the last three years. Medicolegal adviser Dr Jayne Molodynski investigates

Practice managers and GPs regularly seek help from MPS regarding the difficult issue of removing patients from the practice list. The most common queries require advice as to whether a removal is justified, assistance with drafting letters, or support in dealing with a complaint as a consequence of removing a patient.

The latter is becoming more common as highlighted in the latest report from the Parliamentary and Health Service Ombudsman, which describes a 16% increase in the number of complaints about removals.1

MPS recently surveyed 313 practice managers about patient removals. More than half of the practices surveyed removed patients from their list in the last three years for reasons of violence or threatening behaviour, criminal behaviour, and/or deception or other issues resulting in irretrievable breakdown of the doctor–patient relationship (55%).

Of the practices surveyed:

• 49% (152) practices reported removals for violent or threatening behaviour 
• 44% (138) highlighted other issues resulting in an irretrievable breakdown of the doctor–patient relationship 
• 12% (39) for criminal behaviour and/or deception

The stages

1. Breakdown in relationships

Common themes resulting in a breakdown in the relationship between the practice and the patient include:

• Multiple DNAs
• Unrealistic expectations
• Unreasonable demands
• Behavioural issues
• Use of racist or other offensive language.

Practices should, and are, allowed to remove patients where appropriate. It is important that the relevant guidance is adhered to, to avoid the potential for criticisms.

The GMC’s revised version of Good Medical Practice states: “You should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.”2

 

Patients should never be removed solely because of a complaint they have made or because of the resource implications of the patient’s care or treatment

The GMC expands on this statement in their explanatory guidance Ending your Professional Relationship with a Patient, where they provide examples of the rare circumstances in which the trust between a doctor and a patient may break down.3 These include situations where a patient has:

• been violent, threatening or abusive to you or a colleague
• stolen from you or the premises
• persistently acted inconsiderately or unreasonably
• made a sexual advance to you.

The GMC make it clear that patients should never be removed solely because of a complaint they have made or because of the resource implications of the patient’s care or treatment.

2. Before ending the relationship

There are a number of steps practices should take before ending their relationship with a patient:

• Warn the patient that you are considering ending the relationship. The practice is required to make a written record of the date on which a warning was issued, including the reason(s) for the warning as explained to the patient, or the reason why no warning was given. These records must be made available to the NHS England Area Team upon request. 
   
• Where there has been a breakdown in the patient–doctor relationship removal can be considered but, in accordance with the GMS contract, this would normally only be if a warning had been given within the previous 12 months. 
   
• Do what you can to restore the professional relationship. For example, has there been a misunderstanding which can be rectified? Is the patient’s behaviour out of character – could it have been caused by illness, distress or anxiety? Did the practice/doctor in any way contribute to the breakdown?
    
• Explore alternatives to ending the professional relationship. For example, would the patient relate better to a different GP within the practice? Could a meeting with the patient resolve matters and help clear the air? Would an informal agreement over the patient’s future management be helpful, reflecting the responsibilities on both sides? 
   
• Discuss the situation with an experienced colleague or your employer or contracting body. 
   
• The practice must be satisfied that the reasons for wanting to end the relationship are fair and do not discriminate against the patient.4 Patients must never be removed on the basis of race, gender, social class, age, religion, sexual orientation, appearance, disability, medical condition or need for specific treatments.

3. Ending the relationship

 

Record the decision to end the professional relationship – information recorded in the patient’s records must be factual and objective

If the practice decide to end their professional relationship with a patient you must:

• Write to the patient and explain the reason, unless you feel that doing so would be harmful to the physical or mental health of the patient, or would place staff safety at risk, or if it is, in the opinion of the contractor, not otherwise reasonable or practical for a warning to be given (GMS contract).
• Record the decision to end the professional relationship – information recorded in the patient’s records must be factual and objective, and should not include anything that could unfairly prejudice the patient’s future treatment.
• Ensure prompt arrangements are made for the continuing care of the patient and the records must be passed on without delay.
• Notify the NHS England Area Team in writing and removal will take effect eight days after they receive this request. However, if the patient requires treatment at intervals of less than seven days, the practice must continue to deliver care until their condition improves. In this case, removal will commence on the eighth day after treatment becomes less frequent. The exception here is if the patient is accepted onto another practice list sooner than this.
• Be prepared to justify the decision.

Pitfalls

Common pitfalls that can result in complaints and even criticism from the PHSO: 

• Not recording episodes of unacceptable behaviour by patients
• Removal of a whole family when objectively only the removal of one member was justified
• Poorly worded warning letters.

Removals are justified on the grounds of:

• Violence or unacceptable behaviour; if patients have been violent to any members of the practice staff, or have been threatening to the point where there have been fears for personal safety, the incident must be reported to the police straightaway. In these circumstances, the practice can remove the patient from the practice list quickly. Removal takes effect after the practice notifies the NHS England Area Team requesting immediate removal; however, the notification must be confirmed in writing within seven days.

 

Removal takes effect after the practice notifies the NHS England Area Team requesting immediate removal

• Following removal of a patient from a practice list for violent or threatening behaviour, the practice is required to record the fact in the patient’s records and set out the circumstances leading to removal
• Crime or deception such as fraud or theft
• Distance, when a patient has moved outside the practice’s designated catchment area. Removal in these circumstances can occur without a warning although the patient should be given 30 days in which to make alternative arrangements.

Helpful hints

• Draft a practice policy on removing patients and share this with staff so that they are aware of the various sources of guidance and support on this issue
• Warn patients when their behaviour is putting them at risk of being removed from the GP’s patient list
• Ensure warning letters clearly set out what is inappropriate about the patient’s behaviour and what the patient must do in order to avoid being removed from the list
• Try and consider the circumstances from the patient’s point of view
• Carefully consider whether it is necessary to remove more than one member of a family.

References

1. Parliamentary and Health Service Ombudsman, Listening and Learning: The Ombudsman’s Review of Complaint Handling by the NHS in England 2011-12(2012)
2. GMC, Good Medical Practice (2013)
3. GMC, Ending your Professional Relationship With a Patient (2013)
4. GMC, Good Medical Practice, par 56 (2013)

Useful links

• BMA, General Practitioners Committee (GPC), Removal of Patients from GP Lists (2005)
• DH, Health Service Circular, Tackling Violence towards GPs and their Staff(2002)
• MPS factsheet, Removing patients from the practice list (2012)
• Parliamentary and Health Service Ombudsman, Listening and Learning: The Ombudsman’s Review of Complaint Handling by the NHS in England 2010-11(2012)
• GMC, Good Medical Practice (2013)
• GMC, Ending your Professional Relationship With a Patient (2013)