Whilst removing a patient from the practice list due to a breakdown in the doctor/practice’s relationship with the patient should be a rare occurrence, it is the most contentious of reasons for removing a patient from the practice list.
Background
Practices can remove a patient from the practice list in the following circumstances:
- If the patient moves outside the practice area.
- If the patient has died.
- At the request of the patient.
- If there is a breakdown in the doctor/practice’s relationship with the patient.
- Recurrent non-attendance (further guidance in relation to this can be found here).
Other sources of guidance
Other sources of guidance can be found at the links below:
- BMA – Removing patients from your practice list.
- GMC – Ending your professional relationship with a patient.
- GP State of Emergency (GPSOE) did not attend guidance.
What regulations are applicable?
The regulations can be found in the Standard General Medical Services Contract (the same provisions are applicable to PMS and APMS contracts). The relevant regulations are 13.10 (relationship breakdown) and 13.11 (patients who are violent) and they can be found at pages 70-74.
When would it be unreasonable to remove a patient from a practice list?
A practice must have reasonable grounds for removal, which do not relate to the patient’s:
- Age.
- Gender (or gender reassignment).
- Marriage or civil partnership.
- Immigration status.
- Pregnancy.
- Social class.
- Religion or beliefs.
- Sexual orientation.
- Appearance.
- Disability.
- Medical condition.
- Need for specific treatments.
- Relationship to a patient who is to be/has been removed from the practice list.
The other scenario which should be avoided is the bulk-removal of groups of patients who have lived outside the practice area for some time
When is it reasonable to remove a patient from the practice list (non-violent patients)?
Other than violent patients (see below), the contract provisions are silent on what would be a reasonable reason for removing a patient from the practice list.
The usual scenario is that the patient exhibits persistent inappropriate behaviours towards practice staff (which could be both clinical and/or non-clinical staff) that leads to an irrevocable breakdown of the doctor/practice’s relationship with the patient.
It is important that careful consideration be given to the wider circumstances of any incident, including the patient’s perspective. There may be circumstances in which a patient’s behaviour may be mitigated by their condition and/or personal circumstances and it is possible that the matter could have been handled in a better way by the staff member (if so, there may be a training and/or learning opportunity).
A patient may be removed from the practice in the following circumstances:
- The patient has received a warning that they are at risk of removal from the practice list within 12 months of the request for removal (a sample warning letter can be found at Appendix 1 ), unless:
- it would be harmful to the patient’s physical or mental health to do so, and/or
- it would put at risk the safety of a GP, staff member or any other person present on the
practice premises, and/or - it is not otherwise reasonable or practical for a warning to be given.
- The patient has been provided reasons for their removal (if it is not appropriate for a more specific reason to be given then it is reasonable to state that there has been an irrevocable breakdown in
the relationship).
How do I request for a patient to be removed from the practice list?
Practical details as to how you can request for a patient to be removed from the list can be found at Primary Care Support England (PCSE) – patient removals.
When will the removal take effect (non-violent patients)?
The patient will be removed from the practice list on:
- Day eight after the request for removal has been made, or
- the date on which the patient registers with an alternative provider (if sooner).
You must provide care for the patient in the usual way until the removal takes effect.
A sample removals letter (after a warning) can be found at Appendix 2. PCSE also have an obligation to notify both the patient and the practice of the removal from the practice list in writing.
Removing a violent patient from the practice list
A patient can be removed from the practice list if:
- They have committed act of violence against a GP, staff member or any other person present on
the practice premises, and/or - they have behaved in a way such that a GP, staff member or any other person present on the
practice premises has feared for their safety (this would include, but would not be limited to,
verbally aggressive behaviour directed towards staff members), and - the practice has reported the incident to the police.
How do I request for a patient to be removed from the practice list?
Practical details of how you can request for a patient to be removed from the list can be found in the PCSE – patient removals guidance.
The notification can be provided by telephone but must be confirmed in writing within seven days and PCSE will discuss with you the practicalities of referring the patient to the Special Allocation Scheme.
When will the removal take effect (violent patients)?
The patient’s removal from the practice list takes effect at the time of the notification to PCSE (in other words with immediate effect from the time of notification).
Should the patient be informed (violent patients)?
The patient must be informed of their removal from the practice list unless:
- It is not reasonably practical to do so.
- It would be harmful to the patient’s physical or mental health to do so.
- It would put the safety of a GP and/or staff member and/or person on the premises at risk.
PCSE also have an obligation to notify the patient of their removal from the practice list in writing.
Record keeping (violent patients)
The practice must record the removal of the list (of violent patients in the medical records, including the circumstances that led to the removal).
Appendix 1 – Sample warning letter Scenario
Scenario
The scenario in question relates to an incident in which a patient was rude to reception staff.
Please note the following guiding principles:
- The patient may dispute the suggestion that their behaviour was inappropriate, for this reason the sample letter is worded as neutrally as it is possible to do so and focuses on the impact that the behaviour had on the staff members.
- The correspondence should be stored outside the medical records.
- If the reception staff provide witness statements or emails detailing the patient’s behaviour, these should also be stored outside the medical records alongside the correspondence and it should be borne in mind that they would be disclosable in the event that the patient made a Data Subject Access Request under the provisions of the Data Protection Act (2018).
- The sample letter is intended to be a guide only and would need to be tailored to the circumstances of the case.
Sample letter text
Dear <name>
I am sorry to correspond with you in these unfortunate circumstances.
I am writing to you in relation to an incident on <<insert date>> which occurred at the reception desk.
Unfortunately, members of the reception team were left distressed by the way in which you spoke to them / your actions <<delete as appropriate>> and on this basis I am obliged to make contact with you.
<< Observations of the incident – at this stage it would be helpful to include a description or the words and/or actions that led to the distress (it is important to set them out in a factual and nonjudgemental way in order to minimise the risk of the patient disputing what was said or done).>>
I do appreciate that you may have concerns and frustrations in relation to your illness and care, however I am sure that you will understand that it is important that your frustrations do not manifest themselves in a way that causes distress to practice staff.
I hope, that we can now draw a line under this unfortunate matter, however I am obliged to inform you that if there is a repeat incident of a similar nature, the practice will need to give careful consideration as to your ongoing inclusion on the practice list.
Yours etc
Download the warning letter and removal letters as Word templates
Appendix 2 – Sample removal letter after the above warning
The below sample letter follows on from the above warning letter and assumes that there has been a repeat of the behaviour within 12 months of the date of the warning letter.
The same guiding principles relating to warning letters would also apply.
Dear <<name>>
I am sorry to correspond with you in these terms and these unfortunate circumstances.
I am writing with reference to my previous correspondence dated <<insert date of warning letter>>, a copy of which is <<attached/enclosed>> for your reference.
I regret to say that there has been a further incident on <<insert date>> in which members of our reception team were distressed by the way in which you spoke to them.
In the context of the <<attached/enclosed><attached/enclosed>> letter, I indicated that if there was a repeat incident of a similar nature, consideration would be given as to your ongoing inclusion on the practice list.
The practice have given careful consideration to this matter and have decided that as a consequence of the latest incident, there has been an irrevocable breakdown in the relationship such that it is now in the interests of all parties for you to have a fresh start with a new practice.
I have today contacted Primary Care Support England with a request that they remove you from the practice list and my understanding is that they will make contact with you in the near term.
If you wish to contact Primary Care Support England directly, this can be done via their online form or calling: 0333 014 2884.
You must now register with a new practice and I am obliged to inform you that the practice is obliged to provide you up to and including <<insert date (which should be 7 days after the date of this letter)>>, which you will need to seek your care from a new practice from <<insert date (which should be 8 days after the date of this letter)>>.
I indicated at the outset, I am sorry to correspond in these terms and would like to take this opportunity to wish you well in relation to your ongoing care.
Yours etc
Download the warning letter and removal letter as Word templates.