Removing patients from the practice list is an emotive issue, risking criticism from bodies such as the Northern Ireland Ombudsman, the General Medical Council (GMC) and the media and should only be used after careful consideration and as a last resort. The reasons for removing a patient from the list can be varied and will usually require a warning to have been given within the last 12 months. 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 criticism or questions his/her treatment.
The practice leaflet
Your practice leaflet should clearly set out your policy on removing patients from the list and dealing with threatening or violent behaviour on the part of patients. The regulations governing removal from the list are lengthy, but in essence there is one set of rules for people who have been violent or threatening and another for all other circumstances.
The normal procedure: patients who are not violent or threatening
You must have reasonable grounds to remove a patient from the practice list that are fair and non-discriminatory. This should not, for example, be based on factors such as age, religion, medical condition or a relationship to a patient who has already been removed from the list.
Importantly, it is not an appropriate response to remove a patient from the practice list because he or she has complained. GMC guidance 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.”
Removal should only be requested if, during the previous 12 months, the patient has been provided with a warning that he/she is at risk of removal and has been given reasons explaining why this is so.
When 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. This is important as you may be required to justify your decision. These records must be made available to the Health and Social Services Board upon request. You should also consider if there are any steps you can take to improve or restore the professional relationship at this stage.
Where circumstances persist and removal becomes necessary, doctors must notify the Health and Social Services Board that they wish to remove a patient from the practice list, and also notify the patient of the specific reasons for requesting removal. This might be simply that the doctor-patient relationship has irretrievably broken down, provided this is the genuine reason, or if the circumstances make it inappropriate to give a more specific reason.
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 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 not otherwise reasonable or practical for a warning to be given.
All requests to remove a patient must be made in writing and sent to the Board. The General Practitioners Committee (GPC) recommends that the patient is informed in writing about their removal at the same time. Removal will take effect eight days after the Board receives the request. However, if the patient requires treatment at intervals of less than seven days, the practice must continue to deliver care until the patient’s condition improves. The removal will then commence on the eighth day after treatment ceases (unless the patient is accepted onto another practice list sooner than this).
The Board must notify the patient and the practice that the necessary paperwork has been completed and that the patient is no longer on the practice list.
The immediate procedure: violent or threatening patients
In the case of violent or threatening patients, you do not need to have issued a prior warning before the patient can properly be removed from the practice list.
If a patient has been violent or threatening to the point where there are fears for personal safety, the incident must be reported to the police straight away. Behaviour which falls short of the need to involve the police is unlikely to fall within the ‘immediate procedure’ for removal from the practice list and therefore a warning may be required instead.
The practice can then contact the Board (by any means) to request the patient’s immediate removal from the practice list. If not in writing, this notification must be backed up by confirmation in writing (not by fax) within seven days.
Even in these circumstances, the practice should inform the patient of the reasons for his/her removal from the practice list unless:
- 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.
Where a patient is removed from the practice list for violent or threatening behaviour, the practice must record this in the patient’s records and set out the circumstances which lead to the removal.