Removing patients from the practice list is an emotive issue that can open up the potential for criticisms of poor care. Sometimes, though, the doctor–patient relationship breaks down to such an extent that it is in the patients’ best interests for them to be treated elsewhere.

All doctors are entitled to withdraw their treatment of a patient or refuse to treat a patient. You must, however, follow the ethical standards set out in Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (Amended) 8th Edition, which states:

Once you undertake the care of a patient, you should usually continue to care for them for the duration of their illness. If you decide to withdraw your services, you still have an ethical duty to continue to care for the patient until alternative arrangements for care are put in place. Remember, you remain under a duty to provide care in emergency situations at all times.

You must have reasonable grounds to remove a patient from the practice list. You should not remove a patient in response to patients lodging a complaint or failing to comply with treatment, or purely because a patient is highly demanding, offers criticisms, or questions his/her treatment.

Reasonable grounds for removal

• The patient is unlikely to co-operate
• The patient is unlikely to make the lifestyle changes necessary to ensure effective treatment
• The patient is violent or threatening.

You should not remove a patient in response to their lodging a complaint or failing to comply with treatment, or purely because a patient is highly demanding, offers criticisms, or questions their treatment.

If a patient presents a risk of violence, you should make a reasonable effort to assess any clinical cause of the violent behaviour. However, you should not put yourself at risk in carrying out this assessment and may in such circumstances refuse treatment.

If patients have been violent to any members of the practice staff or have been threatening to the point where there have been fears for personal safety, Medical Protection would recommend that the incident should be reported to the Gardaí straight away.

Before making the decision to remove a patient, it’s a good idea to:

• Warn them you are considering ending the relationship
• Do what you can to restore the relationship. Has there been a misunderstanding which can be rectified? Is the patient’s behaviour out of character – could it have been caused by illness, distress, or anxiety? Did the practice or doctor in any way contribute to the breakdown?
• Explore alternatives to ending the professional relationship. Would the patient relate better to a different GP within the practice? Could a meeting with the patient resolve matters and help clear the air? Would an informal agreement over the patient’s future management be helpful?
• Double check that the reasons for wanting to end the relationship are fair and do not discriminate against the patient.

If you do refuse to treat a patient, you should transfer their medical records to their new GP without delay. In some circumstances, it may be appropriate to explain the reasons for your refusal to treat.

Public patients

• If you wish to discontinue treating a public patient, you should advise the Health Service Executive (HSE)/PCRS of this fact and the reasons why.
• Until the patient is registered at a new GP practice, you will retain clinical responsibility. You must provide emergency care to the patient if that is required, during this period of transition
• It’s a good idea to notify the patient in writing that the HSE will make these alternative arrangements for their care, as a matter of courtesy and good practice, and to avoid the patient making a complaint relating to poor communication.
• Once notified of the new GP practice, you should transfer any medical records promptly.

Private patients

• There is no independent regulation for removing private patients from the practice list, apart from the Medical Council’s guidance.

Further reading

• Medical Council, A Guide to Professional Conduct and Ethics for Registered Medical Practitioners (Amended) 8th Edition 2019
• The Health Service Executive (HSE).