A good patient-doctor relationship, based on mutual respect and trust, is the cornerstone of good patient care. The removal of patients from practice lists should continue to be an exceptional and rare event, and a last resort in an impaired patient-practice relationship. When trust has irretrievably broken down, it is in the patient’s interest, just as much as that of the practice, that they should find a new practice.
Practices have the right to ask for a patient to be removed from their list. These provisions require that a reason should be given to the patient by the practice and that normally a warning should have been given by the practice within the past year.
The PCO or NHS England must be informed in writing of the request and the removal will not take effect until the eighth day after the request is received by the PCO or NHS England or, if the practice is treating the patient at intervals of less than seven days, eight days after treatment ceases unless the patient is accepted by, allocated or assigned to another practice sooner than this. The patient is always notified by the PCO or NHS England. There is an exception to this: immediate removal on the grounds of violence e.g. when the police are involved.
Whilst some removals might occur because of disagreement between the practice or individual health professionals, and patients, there are also cases where the practice requests removal because they have become aware that the patient has moved to an address which is outside their practice area. This is necessary because otherwise the practice may still be under an obligation to visit the patient when medically necessary at a location outside their practice area. In such cases, the usual rule will apply that the patient will be removed from the practice list as soon as the PCO is notified that the patient is registered with another practice, or will be removed from the practice list on the eighth day after the PCO is notified of the request for removal.
Patients also have a right to change their practice. They are not required to give their reasons, nor is there any period of notice or requirement to notify the practice.
Public perception of removals
Government figures for removals do not differentiate between those removed because of a breakdown in the relationship and those who are removed for administrative reasons, such as moving to an address outside the practice area. In any case the number of removals must be considered in the context of there being 10,600 practices in the United Kingdom and some 250 million consultations in practices in the course of any one year.
There has been a public perception, fuelled by reports in the media, that patients are being removed from practice lists because their care is too costly, because of their clinical condition or even their age. The GPC supports provisions in the contract that make explicit that any such discrimination is unacceptable. The regulations specifically require that a removal is not on the grounds of “race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition”.
The GPC’s advice
The GPC will defend vigorously the rights of both practices and patients to terminate a relationship that is not working and offers the following advice.
Removals for administrative reasons and change of address
These occur when a patient has died, or has moved to an address outside the practice’s area and has not re-registered.
Breakdown of relationship
- Normally the sole criterion for removal should be an irretrievable breakdown of all or part of the patient-practice relationship, usually that between patient and doctor
- 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 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. Since 1994 it has been possible to request the immediate removal of any patient who has committed an act of violence or caused a doctor to fear for his or her safety. In April 2004 these provisions were extended to make it clear that the provisions extend to anyone else on the premises. 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 the PCO or NHS England, and, other than in exceptional circumstances, the patient of the removal in writing. In such circumstances, the PCO or NHS England can be initially notified by the practice by any means including telephone and fax; however this needs to be followed up by confirmation in writing within seven days. The removal will take effect from the time the practice phones, sends or delivers notification to the PCO or NHS England
- The GPC believes that practices will use their clinical judgement to determine the appropriate course of action in those rare cases where a patient’s violent behaviour results from their medical condition
- It should be noted that if practices do not remove a violent patient under these provisions, and instead use the normal removal process, they may find themselves being asked to justify why they did not do so if a violent patient subsequently registers with another practice, and potentially at risk of action should an untoward incident then take place.
The NHS England Area team, for its part, also has a legal responsibility and a duty of care to ensure that it commissions services to ensure that all patients removed under this regulation can only access NHS primary medical care through appropriately secure arrangements.
If you have any concerns about this or require any other advice in respect of the issue of dealing with violent or potentially violent patients then please do not hesitate to contact your LMC for advice.
Complaints and removals
- The GPC neither supports nor condones the removal of patients solely because they have made a complaint.
The current NHS complaints procedure requires that all practices have an in-house complaints procedure. Patients should normally raise a complaint with their practice in the first instance. There is public concern that patients may be removed from the list simply for making a complaint. However, complaints made in a reasonable and constructive manner can help practices 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. As well as preventing the need for removals, this procedure should reduce the number of incidents where patients appear to have been removed without any prior indication that the relationship with the doctor was less than satisfactory.
The GPC believes, however, that complaints that take the form of a scurrilous personal attack on members of the practice or contain allegations which are clearly unfounded usually indicate a serious breakdown in the patient-doctor relationship.
It is a breakdown of the relationship rather than a complaint per se which must form the basis of any decision to remove a patient from the list; it may then be in the patient’s best interest to seek care at another practice.
- Practices should never remove patients from their list because their treatment is too costly.
There are never any grounds for 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 prescribing budget
- Practices should never remove patients because they are suffering from a particular clinical condition
- Practices should never remove patients on grounds of age. Looking after patients “from the cradle to the grave” is the essence of general practice. Some, but by no means all, elderly patients may have an increased need for medical attention. This is recognised in higher capitation weighting for older patients and normally also in the formula for allocating prescribing budgets.
Sometimes it is not the patients themselves but carers, particularly staff of private nursing and residential homes, who can generate excessive and inappropriate demand for services from the doctor or practice. In these cases the GPC recommends that the practice attempts to resolve the problems through the in-house procedure or using the help of the LMC and the PCO or NHS England
- Practices should never remove patients on grounds of race, gender, social class, religion, sexual orientation or appearance.
What to 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 only be made after careful consideration. Alternatives, short of removal, should be considered such as transferring the patient’s care to a partner (with the consent of both parties) or persuading the patient that it would be better for all concerned for them to go to another practice.
The GPC believes that many patients who are misusing services can alter their behaviour if this is brought to their attention and the regulations normally require a warning to be given within the 12 months prior to removal.
If all else fails the GPC believes that 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.
What constitutes a warning and when is a warning not necessary
A patient must be warned that they are at risk of removal, together with an explanation of the reasons for this, within the period of 12 months before the date of the request to the Primary Care Organisation. Whilst warnings do not have to be in writing it is good practice for them to be so as this allows for carefully considered reasons to be given.
A permanent record of the warning, including the date and reason for the warning, must be made and retained as the PCO or NHS England may require sight of them. Copies of such records must therefore be retained after the patient has left the list.
However no warning is required if:
- The removal is on the grounds of change of address
- The practice has reasonable grounds for believing that the issue of such a warning would be harmful to the physical or mental health of the patient
- The practice has reasonable grounds for believing that the issue of such a warning would put at risk the safety of members of the practice or those entitled to be on the practice premises
- It is, in the opinion of the contractor, not otherwise reasonable or practical for a warning to be given.
If no reason is given an explanation in writing should be made and retained for potential future inspection by the PCO or NHS England.
How to remove a patient from the list if necessary
- Where practices intend to remove a patient because of the irretrievable breakdown of the doctor-patient relationship, they should first consider discussing the problem confidentially with an independent party, such as their LMC secretary
- Practices should issue a warning, preferably in writing, giving the reasons for the possibility of removal.Warnings are valid for 12 months and a written record must be retained
- Practices should send a written notice to the PCO or NHS England, giving the patient’s name, address, date of birth, and NHS number. They should state that they wish to have the patient removed from their list under the terms of their agreement or contract
- If the removal is on grounds of violence or threatened violence the police, or Procurator Fiscal, must have been informed; there is no obligation to ask them to pursue the matter
- The practice must notify the patient of the removal with an explanation for the removal. The GPC recommends that this should be in the form of a letter to the patient briefly outlining the reasons. A copy of the letter should be retained.
Removing other members of the household
If the behaviour of one member of a household or family has led to their removal, this does not mean that the removal of other family members should automatically follow. An explicit discussions, whilst protecting the confidentiality of the removed patient, with other family members about the problem and the doctor’s concerns will often obviate the need for any further action.
In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to look after the whole family. This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members as patients could put doctors or their staff at risk.
Again the GPC would suggest that reasons are given clearly in the case of a removal. The practice should always consider how it would look to outside observers if a family were to be summarily removed from the list in haste and without explanation for a single misdemeanour or disagreement with one family member.
It may be helpful if practices set out in their practice leaflets the arrangement for removal of patients from the list, and their policy for dealing with threats or incidents of violent behaviour.