MPS general practice complaints advisers Terri Bonnici and Sue Taylor share how practices can effectively manage patient removals
Removing a patient from a practice list should be done with care and consideration or a complaint will almost certainly be a consequence of the action. Where there has been a breakdown in the patient–doctor relationship removal can be considered but, in accordance with the GMS contract, this would normally only be if a warning had been given within the previous 12 months. This would include patients who have exhibited unreasonable behaviour which has not warranted an immediate removal.
When considering the possibility of removal under these circumstances you should ask yourselves the following questions to explore the reasons for the breakdown:
- 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/doctor in any way contribute to the breakdown?
Then consider if there is anything that can be done to reestablish a good relationship. For example:
- 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, reflecting the responsibilities on both sides?
When a removal is undertaken you should write to the patient and explain the reason, unless you feel that doing so would be harmful to the physical or mental health of the patient or would place staff safety at risk.
Failure to follow due process can lead to criticism and possible financial sanctions should the complaint be upheld by the Ombudsman. Be aware of the guidelines issued by the RCGP, BMA and the GMC and be familiar with your obligations under your GMS contract.
Key things to remember are:
- Ensure that any unacceptable behaviour is noted as part of your incident reporting procedures.
- Removal of one member of a household should not necessarily lead to the removal of other family members and you would need to justify your reasons for doing so.
- A poorly worded warning can result in a complaint and harm the relationships even further.
- Seek advice when uncertain.
Patients should NEVER be removed on the following grounds:
- Solely on the basis that the patient has raised a complaint
- Cost or complexity of treatment and clinical need
- Sexual orientation
Removals are justified on the grounds of:
- Violence or unacceptable behaviour to the extent where the police have been involved. This would enable you to instigate an immediate removal.
- Crime or deception such as fraud or theft.
- Distance, when a patient has moved outside the practice’s designated catchment area.
Removal can be considered on the grounds of:
- A breakdown in the patient-doctor relationship.
Mr A arrived for his morning appointment at his local GP practice. Mrs C, a receptionist, informed him that his GP was running late this morning. After waiting for 30 minutes, Mr A became very aggressive towards Mrs C and soon left without being seen. Mrs C was very upset by the experience and felt very intimidated and unsafe.
The practice discussed the matter at a practice meeting and decided that they would remove Mr A under Zero Tolerance due to a breakdown in the practice–patient relationship. They wrote to Mr A informing him of this decision and asked the local commissioning body to organise an eight-day removal. Mr A complained about the removal stating that the way the practice had treated him had caused him to become annoyed, but that no-one had asked him for his side of the story before taking steps to remove him from the list.
The practice had responded explaining their Zero Tolerance policy, but Mr A had remained dissatisfied and approached the Ombudsman.
The Ombudsman concluded that due process had not been followed in removing the patient in that there had been no warning letter sent within the previous 12 months. She was also critical that there was no contemporaneous incident report, only a statement made by the member of staff as part of the complaint investigation. The practice was asked to apologise to the patient for not following the correct procedure and to pay him £250 for the distress and inconvenience caused by the removal.
What should have happened
There were a number of trigger points during this story which, if handled differently, could have prevented the situation occurring and supported any further action the practice may have taken.
When it became clear that Mr A had been kept waiting an apology could have been given, the reason for the delay explained and the offer made to rebook the appointment.
A warning letter should have been sent to the patient inviting his comments on the situation. (See example letter that could have been sent.)
The event should have been recorded as an incident (separate from the patient’s records) with statements taken from the staff member involved and any staff who witnessed what happened. This would support the reason for the warning letter and act as supportive evidence should the time come to remove the patient.
Example of letter that could have been sent:
Dear Mr A
I am writing following an incident, which occurred in the practice yesterday when you attended for your appointment with Dr G. We are sorry that you were kept waiting so long beyond your appointment time to the extent that you felt you needed to leave before you were seen. Unfortunately Dr A had to attend to an emergency earlier that morning which had put his appointments back by some 30 minutes. I apologise if this was not made clear to you at the time and options offered. Please do return to the surgery if you are still concerned about your condition.
Whilst I can appreciate how frustrating this situation must have been for you the receptionist did find your attitude towards her rather intimidating and this did cause her some considerable distress. However, we would be happy to receive your own comments as we do recognise that your own perception of events is equally valid. It is possible that you may not have realised the impact your behaviour had on the receptionist. However I hope you will understand that we do have a Zero Tolerance Policy and any repeated incidents of a similar nature could result in us considering your future with the practice.
Thank you for taking the time to read this letter and, as mentioned, we would be happy to receive any comments you may have as we appreciate that your own perception of events may differ and we would welcome your feedback and the opportunity to resolve any misunderstandings.
Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.