Patient Removal Policy

Introduction

Removing patients from the Practice lists is an exceptional and rare event, which will be considered a final resort where the patient-practice relationship has broken down irretrievably.

In some circumstances it can be considered reasonable, or in the best interests of the patient, to remove patients from the list. The purpose of this policy, therefore, is to define the practice guidelines for removal of a patient from the practice list and to ensure that any concerns about removing patients from the list are dealt with fairly.

SITUATIONS WHICH JUSTIFY REMOVAL

Violence or Unacceptable Behaviour

If a patient has displayed any violent, abusive, or threatening behaviour towards the GP or any other member of Practice Staff that has required police intervention, that person can be removed without warning from the Practice patient list immediately.

When a patient: –

Is physically violent or threatening towards a doctor, practice staff or other patients on the practice premises.
Causes physical damage to practice premises or another patients’ property.
Gives verbal abuse or makes threats towards the doctor, practice staff or other patients.
Gives racist abuse, orally or physically.
Sexual harassment of Practice staff or other patients.
Stalking or inappropriate attachment to a GP or other member of staff.
Is violent or uses or condones threatening behaviour to doctors (or some other members of the primary health care team) while visiting the patient’s home. Such behaviour may involve the patient, a relative, a household member, or pets (such as unchained dogs). *

*Removal can extend to any family living at the same address as any future visits may expose practice staff to harm if visiting the home, or if the perpetrator attends the Practice with a family member.

Crime & Deception

Where a patient: –

Fraudulently obtains drugs for non-medical reasons.
Deliberately lies to the doctor or other member of the primary health care team (e.g. by giving a false name or false medical history) in order to obtain a service or benefit by deception.
Attempts to use the doctor to conceal or aid any criminal activity.
Steals from practice premises.

Embarkation

Where a patient has moved abroad for a period of 3 months or more.

Other Reasons

Where a patient fails to attend pre-booked appointments on a number of occasions during a given period.
Irretrievable breakdown of the Doctor/Nurse-Patient relationship.
Where a patient’s behaviour falls outside of that which is normally considered reasonable and leads to an irretrievable breakdown of the doctor-patient relationship

IF REMOVAL APPEARS NECESSARY (ISSUING A WARNING LETTER)

In cases that do not involve violence or abuse, the decision to remove a patient should be taken after careful consideration. You may want to consider alternative solutions, such as transferring care to another GP. Patients who are abusing or misusing Practice services or staff should be given the opportunity to alter their behaviour if this is brought to their attention in the form of a warning letter. See Appendix 1.

A patient should have been issued a warning letter that they are at risk of removal (along with an explanation) within the last 12 months prior to removal. It is good practice to have warnings in writing as this allows the opportunity to present and consider the reasons to be given for possible removal.

A record of the warning (including date, time and reason) must be kept by the Practice as the Local Area Team or NHS England may request a copy, and copies should be retained by the Practice after the patient has left the Practice List.

SITUATIONS THAT DO NOT JUSTIFY REMOVAL

Complaints

A patient cannot be removed from a Practice list if they have made a complaint (formal or informal), nor for occasionally or persistently questioning clinical techniques, safety measures or other practice matters.

However, it may be agreed if the basis of the complaint results in the relationship between the GP and the patient breaking down and cannot be resolved (either because of complaints or legal action), that the patient may be advised to change their Practice.

Patient Choice on Clinical Matters

Choosing a valid course of treatment that may be problematic for the practice (e.g. home treatment or confinement)
Refusing to take part in local or national screening programmes (e.g. cervical screening)
Refusing to take part (or allow dependants to take part) in local/national preventive medicine programmes (e.g. child immunisations)
Does not comply with health advice given by GP.

Other Reasons

Patient has highly dependent condition or disability.
Treatment is considered to be too expensive.
If patient has high degree of concern or anxiety about their condition.
Discrimination of any nature against the patient and/or their relatives.

PROCEDURE FOR REMOVAL

Violence / Crime and Deception

Any incident involving violence, crime or deception will be immediately reported to Roberta James, who will complete an incident report and bring it to the attention of the practice partners. Staff involved should also make a written statement at the time as further evidence. It may be so serious that the police may need to be contacted.

If the Police are contacted, the patient can be removed immediately by contacting the Commissioning Group / Registration Department/PCSE, advising them of the incident and giving them a log number that the police have given.

For Less Serious Matters

Each case will be discussed with all involved in the surgery and a partner. A majority agreement will be reached. If it is to remove the patient it can be done under the 8-day rule. The Commissioning Group and Registration Department/PCSE will need to be contacted and a brief outline given.

Following that agreement, the Practice Manager will write to the patient and explain the reasons for removal. See Appendix 2 for sample text. The Registration Department should then deduct the patient in the normal way. The patient is entitled to the continuation of care during those 8 days

Distance

On notification that the patient is no longer living within the practice boundary, and if it is impractical for the patient to remain registered at the surgery, a letter will be sent to the patient advising of the need to re-register within 28 days elsewhere.

Notification will be sent to the Registration Department/PCSE after 28 days if the patient has not been deducted by the Registration Department as they have not registered elsewhere.

Embarkation

On notification that the patient has moved abroad the patient will be removed from the Practice list within 3 months of that notification.

Failure to attend pre-booked appointments

If a patient fails to attend a pre-booked appointment on more than (3) occasions in the last year, a warning letter will be sent to the patient, advising them that a further occurrence could risk removal from the practice.

Warning letters are valid for a period of 12 months. Removal based on warnings greater than 12-months-old will be invalid – in this case a further formal warning and period of grace will be required.

If the patient fails to attend another appointment, the matter will be discussed at a practice meeting and a majority agreement will be reached as to whether the patient will be removed from the practice list. Following agreement, Roberta James will write to the patient and explain the reasons for removal.

Guidance on removing patients due to irretrievable breakdown of the doctor – patient relationship.

Occasionally patients persistently act inconsiderately, and their behaviour falls outside that which is normally considered to be reasonable. In such circumstances there may be a complete breakdown in the doctor-patient relationship.

Steps to be taken within the Practice

Inform all appropriate members of the practice about the problem.
Possible reasons for the patient’s behaviour (e.g. disagreeableness, cultural differences, mental illness, and personality disorder) will be discussed at a practice meeting.

Steps to be taken with the Patient

Inform the patient, either personally or in writing, that there is a problem.
Explain the nature of the problem to the patient.
Obtain the patient’s perspective and interpretation of the situation.
Obtain advice of a Medical Defence Organisation.

Steps to be taken if discussion fails to resolve the problem

Suggest that another GP within the practice might better fit with the patient’s needs and expectations. (THIS MAY NOT BE POSSIBLE IN SMALL PRACTICES)
Steps to be taken in actually removing the patient.
Inform the appropriate Registration Department/PCSE in writing of your decision.
Inform the patient in writing of the decision and the reason for removal from the list.
Explain to the patient that he or she will not be left without a GP.
Give the patient information on how to begin the process of registering with another GP.

Steps to take if agreement is reached not to remove.

In some cases the removal may be queried by the patient or family. It is good practice to facilitate a meeting to look at if differences can be worked through.
If agreement can be reached not to remove a patient after discussions, then it should be documented in writing to the patient the agreement and what is expected from both sides.

Family Members

When a decision is made to remove a patient from the practice list, the removal may well be extended to other members of the family or household. Careful thought must be given to this as it is not always necessary to remove family members.

Removing other members of the household

If the behavior of one member of a household or family has led to their removal, this does not mean that the removal of other family members should automatically follow. An explicit discussion, whilst protecting the confidentially of the removed patient, with other family members about the problem and the doctor’s concerns will often obviate the need for any further action.

In rare cases however, because of the possible need to visit patients at home, it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behavior resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family.

This is particularly likely where the patient has been removed because of violence or threatening behavior and keeping the other family members could put doctors or their staff at risk.

The practice should always consider how it would look to outside observers if a family were to be summarily removed from the list, in haste, without explanation, for a single misdemeanor or disagreement with one family member.

Roberta James will write to the family / household, offering an explanation for the removal. They will be allowed four weeks to re-register rather than being removed from the practice list immediately.

Responsibility

Responsibility for implementing and monitoring the policy rests with the Practice Partners / Practice Manager.

The practice re-affirms its commitment to do everything possible to protect staff, patients and visitors from unacceptable behaviour and their zero-tolerance approach to any incident that causes hurt, alarm damage or distress.

Steps to be taken to remove the Patient

Inform your NHS Local Area Team/PCSE in writing of the decision to remove the patient, including the reasons and circumstances that have led to this decision.
Write to the patient informing them of the decision to remove the patient and the reason for doing so (you may want to get the advice of your Medical Defence Organisation before writing to the patient). Usually the timescales given can start from seven days.
Provide information for the patient to register with another practice.
If it is believed that the letter will result in a violent response from the patient towards the Practice, then the patient can be told by the most senior member of staff present at the time of the incident that they must not return to the practice. Information about finding a new GP can be found by the patient by contacting the Primary Care Organisation (usually the Local Area Team).

All requests for the Practice to remove a patient from the Practice List must be made in writing to your NHS England Local Area Team/PCSE (a list of LATs is available here).

Removal is expected to take effect Eight days following the LAT’s receipt of this request. If a patient’s treatment is to be administered at intervals of seven days or less, then the Practice must continue to deliver this care until their condition improves (unless the patient is registered with another practice before this time).

The Local Area Team must notify both the Practice and the excluded patient that the required paperwork has been completed and confirm that the patient is no longer registered at the Practice or on the Practice List.