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:
- the contractor, where the contractor is an individual medical practitioner;
- in the case of a contract with two or more persons practising in partnership, a partner in the partnership;
- 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;
- a member of the contractor’s staff;
- a person engaged by the contractor to perform or assist in the performance of services under the contract; or
- any other person present—
- on the contractor’s practice premises, or
- 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:
- 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.