Removing patients from the practice list is an emotive issue, risking criticism from bodies such as the Parliamentary and Health Service Ombudsman, the GMC and the media and should only be used as a last resort. The reasons for removing a patient from the list can be varied, but it should not be in response to patients lodging a complaint or failing to comply with treatment. Nor should it be used purely because a patient is highly demanding, offers criticisms or questions his/her treatment.
The practice leaflet
Your practice leaflet should set out your policies on removing patients from the list and on threatening or violent behaviour on the part of patients.
Patients who are not violent or threatening
You must have reasonable grounds to remove a patient from the practice list. Your reasons cannot be based on the patient’s:
- Social class
- Sexual orientation
- Medical condition
- Need for specific treatments
- Relationship to a patient already removed from the list.
Removing a patient from the practice list is not an appropriate response to a complaint. The GMC states: “You should not end a professional relationship with a patient solely because of a complaint the patient has made about you or your team, or because of the resource implications of the patient’s care or treatment.”
Doctors have to notify their NHS England Area Team if they wish to remove a patient, and also notify the patient of the specific reasons for requesting removal. This might simply be that the doctor-patient relationship has irretrievably broken down, but this may only be given as a reason if it is the genuine reason, or if the circumstances make it inappropriate to give a more specific reason.
Removal should only be requested if, during the previous 12 months, the patient has been provided with a written warning that he or she is at risk of removal and has been given reasons explaining why this is so. Removal without warning can only occur if:
- The patient has moved outside the doctor’s practice area (although he/she should be given 30 days in which to make alternative arrangements, the practice is not responsible for visiting or treating the patient during this period).
- The doctor has reasonable grounds to believe that issuing a warning would be harmful to the patient’s mental or physical health, or put practice staff at risk. It is, in the opinion of the contractor, not otherwise reasonable or practical for a warning to be given (GMS contract).
If a warning is given, the practice is required to produce a written record of the date on which it was issued, including the reason(s) for the warning as explained to the patient, or the reason why no warning was given. These records must be made available to the NHS England Area Team upon request.
All requests to remove a patient from a practice list must be made in writing and sent to the NHS England Area Team. Removal will take effect eight days after the NHS England Area Team receives this request. However, if the patient requires treatment at intervals of less than seven days, the practice must continue to deliver care until his/her condition improves. In this case, removal will commence on the eighth day after treatment becomes less frequent. The exception here is if the patient is accepted onto another practice list sooner than this.
The NHS England Area Team must notify the patient and the practice that the necessary paperwork has been completed, to confirm that the patient is no longer on the practice list.
Violent or threatening patients
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, the incident must be reported to the police straightaway. In these circumstances, the practice can remove the patient from the practice list quickly.
Removal takes effect after the practice notifies the NHS England Area Team, requesting immediate removal. The notification must be backed up, however, by confirmation in writing within seven days.
NB faxed confirmation does not qualify as written confirmation.
Even in these circumstances, the practice should inform the patient of the reasons leading to removal from the practice list unless one or more of the following apply:
- It would be harmful to the mental or physical health of the patient
- It would put practice staff or patients at risk
- It would not be reasonably practicable to do so.
Following removal of a patient from a practice list for violent or threatening behaviour, the practice is required to record the fact in the patient’s records and set out the circumstances leading to removal.
The National Health Service (Primary Medical Services) (Miscellaneous Amendments) Regulations 2012 makes provision for the establishment of an outer practice boundary area, in addition to the current practice boundary. It is a statutory requirement for practices to publicise the fact that they have an outer boundary and they may have to justify why patients have been removed from their list whilst remaining in the outer boundary.