GP practices

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The removal of patients who are violent and the Special Allocation Scheme (SAS)

This guidance should be read in conjunction with BMA guidance covering the removal of patients from GP lists.

GP practices will sometimes find themselves in a situation where they are faced by a patient that is violent, aggressive or exhibits other such behaviour that makes them fear for their safety. In these situations that patient needs to be removed from their practice list without delay. This guidance seeks to ensure they understand how this can be done promptly, minimising risk to themselves and their staff while complying with the GMS regulations. There is an equivalent provision for PMS practices.

 

The Special Allocation Scheme (previously known as violent patient scheme or zero tolerance scheme)

The Special Allocation Scheme was introduced as a Directed Enhanced Service in 2004 to provide general primary care medical services in a secure environment to patients who meet the criteria for inclusion into the scheme. Designated GP practices provide services to patients by prior appointment and at specific locations and times as detailed in individually agreed contracts. Patients are allocated to the scheme following a process of immediate removal as a result of an incident that has been reported to the police.

 

Purpose

The purpose of the scheme is to deal with patients who are aggressive and abusive, as well as, in some cases, violent. In doing so it aims to protect GPs and practice staff, and allows them to carry out their roles safely, in addition to protecting the safety of patients and other visitors. All staff have the right to work without the fear of intimidating behaviour, whether actual or perceived, and it is vital that any scheme commissioned to allow them to do so is robust and operates efficiently and in line with the regulations, whilst being appropriately supportive of the patient.

 

Problems

The regulations provide for the immediate removal of a patient from a practice list following a request to the Board (NHS England). This is enacted by PCSE on behalf of the Board. The initial request can be by phone or in writing, but all phone reports must be followed in writing within 7 days. GPC had been made aware of some schemes that required Commissioner intervention of some sort before a removal is actioned. This is not in line with the provisions set out in the regulations and NHS England has addressed this through amendments to a single national process.

While the revised scheme settles down, any examples where the regulations seem not to be applied correctly, should be raised with LMCs for escalation to NHS England’s national team.

To progress an allocation to the SAS, the regulations require a practice to report an incident to the police, but they do not require the practice to obtain a police incident number or crime number before a removal is actioned, and the SAS recognises that the absence of an incident number at the first point of reporting is not an impediment to the immediate removal of a patient whose behaviour is such that they meet the criteria for removal. NHS England may seek such information as part of a reasonable request for information. GPC would support this and suggests that being unable to obtain and supply an incident number within 7 days of the initial report would only be the case in exceptional circumstances.

 

  • When is removal appropriate?

    The regulations state that in order to have a patient removed from its list, a contractor must have grounds that an individual has committed an act of violence against any of the persons specified below, or has behaved in such a way that any of those persons has feared for their safety. Those persons are:

    1. the contractor, where the contractor is an individual medical practitioner;
    2. in the case of a contract with two or more persons practising in partnership, a partner in the partnership;
    3. in the case of a contract with a company limited by shares, a person who is both a legal and beneficial owner of shares in that company;
    4. a member of the contractor’s staff;
    5. a person engaged by the contractor to perform or assist in the performance of services under the contract; or
    6. any other person present—
    1. on the contractor’s practice premises, or
    2. in the place where services were provided to the person under the contract*.

    It follows that the regulations relating to violent behaviour should not be used to remove patients where the situation is more akin to a breakdown in the relationship between the patient and the GP and where removal is possible so long as the contractor has reasonable grounds that do not relate to the person’s age, appearance, disability or medical condition, gender or gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sexual orientation or social class.

    If the practice is unsure whether an incident falls within the criteria to request an immediate removal, it is important to remember that the principle underlying the regulations is that immediate removal is justifiable where an incident results in any ‘fear for safety’.

    In terms of what behaviour would justify immediate removal of a patient, there is no exhaustive list. Practices are expected to make a judgment based on the wording above, ensuring they exercise a duty of care to their staff at every stage of the process. This is necessarily subjective and therefore always a decision for the practice. However, the main kinds of behaviour that would justify removal are:

    • Assault
    • Threatening behaviour
    • Behaviour resulting in damage to property

    Included under these headings would be situations where a patient:

    • struck, grabbed or punched a GP, member of staff or other individuals, either within the practice premises, or elsewhere, if in a targeted attack
    • thrown an inanimate object at a GP, or member of staff either within the practice premises or elsewhere, if in a targeted attack
    • struck, grabbed, punched or thrown an inanimate object at another patient(s) within the practice premises
    • wielded a weapon, or used an object as one, in an actual or intended assault, or in a manner intended to intimidate or terrorise staff, patients or other persons on the practice premises
    • threatened to assault or physically harm a primary care worker
    • threatened to damage property or to ‘seek revenge’ in a menacing way
    • caused damage to property with an intention to intimidate or cause harm.

    Even where a patient exhibits behaviour that would not justify immediate removal, any person subject to that behaviour, should still report the incident. In doing so, they should expect the practice to take action necessary to address the incident and ensure there is no repeat, even if this does not amount to immediate removal.

    In situations where practices are still not clear what the correct procedure is for any particular incident, they can seek further support, advice and guidance from their Local Medical Committee, or the commissioner.

     

    * Following the successful conclusion of the 2017/2018 contract negotiations, there will be some amendment to these regulations, which are expected in October.

  • The process of removal

    When an incident occurs that justifies the immediate removal of a patient, the practice should ring 999, or their local police station, whichever is more appropriate, as soon as it is reasonably practical to do so and if necessary, request police assistance at the incident location. They should state what has happened and the situation should then be handled as considered appropriate following discussion between the practice and police. At the time of the call, the police will allocate an incident number that can be requested by the practice.

    The regulations then require the contractor to notify 'the Board' (NHS England). A practice may do by any means (e.g. phone/email) to PCSE which has been appointed as NHSE’s agent in delivering this support. If the initial report is done by phone it must subsequently be confirmed in writing, before the end of a period of seven days beginning with the date on which notice was given. (Schedule 3, Part 2, paragraph 25). Notification via PCSE can be by telephone (0333 014 2884), or e mail: [email protected]. PCSE has produced a proforma for this. NHS England and GPC recommend practices use the proforma as this can be accepted as the practice’s written report, where the necessary information has been provided within.

    It is important to note that when a removal is requested in this way, it takes effect at the time at which the contractor makes the call to ‘the Board’, or sends the email i.e. immediately (actioned by PCSE on the same day when received before 15:00, or the next day if later).

    Having done so, the contractor also has a responsibility to inform the patient of the removal, unless it is not reasonably practical to do so, or if to do so would be harmful to the patient’s physical or mental health, or put any of the people listed above at risk.

    Finally, there is a statutory requirement for contractors to notify the CQC "without delay" if certain specific incidents take place while a registered activity is actually being provided, or was a consequence of its being provided. This includes incidents reported to, or investigated by, the police.

  • The process following the report to the police

    At this point responsibility for the removal process passes to PCSE. They must ensure the patient no longer remains on the practice list, but that they can continue to receive primary medical services if they wish. The primary care provider will be through a commissioned SAS provider. PCSE will write to the patient to inform them of this process. Importantly, PCSE must ensure a flag is placed on the patient record to prevent them registering at another practice.

    The removal of a patient and their allocation to the SAS remains under review by a panel responsible for monitoring the ongoing appropriateness of the removal, allocation and rehabilitation of the patient at set times. The purpose of this review is to ensure the patient can be reintegrated into mainstream Primary Care.