GP - removal of patients from their lists
August 2005
A good doctor-patient relationship, based on mutual respect and trust, is the cornerstone of good patient care. The removal of patients from general practitioners' lists should continue to be an exceptional and rare event, and a last resort in an impaired doctor-patient relationship. When trust has irretrievably broken down, it is in the patient's interest to find a new GP.
Patients also have a right to change their doctor. They are not required to give reasons or any period of notice and there is no requirement for the GP to be notified.
Most removals of patients from GPs’ lists occur for administrative reasons, for example because the patient has moved to an address outside the practice area or has died. Violence or threatening behaviour by the patient is a special case where removal is justified. Otherwise, the sole criterion for removal should be an irretrievable breakdown of the doctor-patient relationship.
GPs have the right to request that any patient should be removed from their lists ( reference 1). Where a practice has reasonable grounds to remove the patient from its list of patients, it must inform the primary care organisation (PCO) in writing, and must notify the patient in writing of the reasons for removal. However, where the practice believes that it is not appropriate to give specific reasons it is sufficient to state that there has been a breakdown in the relationship between the practice and the patient. Care should be taken to ensure that the reasons given are factual and that the tone of the letter is polite and suitable informative.
The removal will not take effect until the eighth day after the request is received by the authority ( reference 2) unless the patient is accepted by, allocated or assigned to another GP sooner than this. The patient is always notified by the PCO.
The General Practitioners Committee (GPC) recommends that when GPs send the request to the PCO they should also consider sending a brief letter to the patient informing them of the removal and briefly outlining the reasons. There are two reasons for suggesting this:
Firstly, it is a matter of common courtesy. Even in circumstances where patients have been less than courteous it is essential for doctors to maintain their standards of professionalism.
Secondly, it will help to avoid or counteract any public speculation about the doctor's motivation.
Statistics on removals and public perception
Latest figures for England and Wales ( reference 3) show:
- 74,695 patients were transferred at the request of the GP in England and 2,464 in Wales
- 3,213 patients were transferred at the request of the patient in England and 400 in Wales.
- 1,081 patients were removed from a GP’s list because of an act or threat of violence in England and 121 in Wales.
Unfortunately some cases have given rise to unfavourable publicity for the doctor and practice concerned or for GPs in general. A number of aggrieved patients have claimed that they do not know why they have been removed.
There is also an increasing public perception, fuelled by reports in the media, that patients are being removed from their GP's list because their care is too costly. In addition a few reports have alleged that patients were removed because of their clinical condition.
General Practitioner Committee advice to GPs
The GPC defends vigorously the rights of both doctors and patients to terminate a relationship that is not working but would offer the following advice:
Breakdown of the doctor-patient relationship - in the vast majority of cases the sole criterion should be irretrievable breakdown of the doctor-patient relationship. There will be occasional exceptions to this rule such as where a patient has moved to an address outside a doctor's practice and will not re-register with a GP in that area.
Violence or threatening behaviour by the patient - violence or threatening behaviour by the patient is a special case. It usually implies a total abrogation by the patient of any responsibility towards the doctor 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.
It is now possible to request the immediate removal of any patient who has committed an act of violence or caused the doctor to fear for his or her safety. The police (or in Scotland, either the police or the procurator fiscal) must have been informed of the patient's behaviour and the doctor must notify both the PCO and the patient of the removal in writing.
GPs will use their clinical judgement to determine those rare cases where a patient's violent behaviour results from their medical condition.
Complaints - the GPC does not support or condone the removal of patients solely because they have made a complaint.
The current NHS complaints procedure has now been in operation since 1996 and it is a requirement under the terms of service for all GPs to ensure that their practice has an in-house complaints procedure. Patients should normally raise a complaint with their practice in the first instance.
There has been public concern that patients may be removed from the list simply for making a complaint. However, a complaint made to the practice in a reasonable and constructive manner can sometimes help GPs to improve services to patients. It is also perfectly possible to use the practice-based complaints procedure to discuss any instances where a patient is felt to be behaving inappropriately. This gives patients early notification of a possible problem in their relationship with their doctor along with an opportunity to discuss ways of preventing further difficulties.
However, complaints that take the form of a scurrilous personal attack on the doctor or contain allegations which are clearly unfounded are usually indicative of a serious breakdown of the patient-doctor relationship.
It is the breakdown of the relationship rather than the complaint per se which forms the basis on which the GP may justifiably decide to remove the patient from the list. It may be in the patient's best interest to seek care at another practice.
Cost - GPs should not remove patients from their list because their treatment is too costly. There are no grounds for ever removing patients because of cost. Where the costs of treating an individual patient are higher than anticipated, adequate mechanisms exist to enable doctors to seek and be granted an increase in their fund or prescribing budget.
Clinical conditions - equally the GPC could not defend the removal of a patient because they are suffering from a particular clinical condition. The GPC is striving continuously to ensure in discussions with government that any arrangements emerging from the NHS changes do not operate to the detriment of patient care and that GPs are able to provide all necessary and appropriate clinical care for their patients without financial penalty.
What GPs can do if removal appears to be necessary
In cases other than violence and abuse, the GPC recommends that the decision to remove a patient from the list should be considered carefully and preferably not made in the heat of the moment.
The GP will consider alternatives such as transferring the patient's care to a partner (with the consent of both parties) or persuading the patient that it will be better for all concerned to go to another doctor outside the practice.
Patients who are misusing services may sometimes alter their behaviour if this is brought to their attention. It may be appropriate to advise them that continued misuse may lead to their removal from the list.
If all else fails, it is not in the best interests of either patient or doctor for an unsatisfactory relationship to continue and it will be necessary to remove the patient from the list.
Other members of the household
If the behaviour of one member of a household or family has led to their removal, GPs will use their judgement about other members. Sometimes an explicit discussion with other family members about the problem and the choices which they have will be helpful.
In rare cases, however, because of the duty to visit patients at home it may be prudent to terminate responsibility for the entire household or other members of the family. Reasons should be given for this decision.
Practice leaflets
It may be helpful if GPs set out in their practice leaflets the arrangements for removal of patients from the list and their policy for dealing with threats or incidents of violent behaviour.
1 This is enshrined in the new General Medical Services contract - paragraphs 192-201
2 or eight days after treatment at intervals of less than seven days ceases
3 General and Personal Medical Services Statistics, England and Wales, 30 September 2004
For further information, please contact the parliamentary unit:
Email: parliamentaryunit@bma.org.uk