A FIFTH of all complaints about GPs in England that were investigated in 2010 were about patient removal from surgery lists, according to recent figures on NHS performance.
GPs came in for considerable criticism when these figures were published last month by the Parliamentary and Health Service Ombudsman. They revealed more than 15,000 complaints had been made about the NHS in 2010/2011. And while most of these were resolved locally, 21 per cent of those investigated further were about patient removals – a rise of six per cent on the previous year. The ombudsman accepted 13 complaints for investigation about removal from GP lists and upheld 10.
MDDUS has handled a number of cases and advice calls regarding the removal of patients from practice lists. Any doctor who is considering removing a patient must think carefully before doing so and follow guidance set by the General Medical Council, the Royal College of General Practitioners and the British Medical Association, as well as considering the requirements of their GMS contract.
Deviating from these guidelines – which apply to doctors across the UK – could lead to patient complaints and even attract the attention of the GMC.
Following publication of the report on NHS complaints, ombudsman Ann Abraham expressed concerns that “far too often” GPs don’t seem to be aware that their contracts require them to give a warning before a patient is removed “unless the circumstances are exceptional.” She said that in “far too many cases [what we see] is a knee-jerk response to a single incident where an individual – sometimes a whole family – is removed.”
RCGP guidance Removal of Patients from GPs’ Lists – Revised Guidance for College Members, from September 2004, is clear about what doctors must do. It advises practices to provide leaflets explaining their removal policy and the circumstances that might lead to its implementation. Patients should always be given a reason for their removal except in exceptional circumstances where this could increase the likelihood of unacceptable behaviour, such as violence or harassment, towards the doctor or practice staff.
Where the relationship breaks down between a doctor and patient, practices are encouraged to consider continuing treatment for the patient via another doctor within the practice. But the guidance adds: “Where a patient’s continued registration with the practice might be detrimental to the primary healthcare team as a whole, GPs retain the right to remove a patient from the practice list. The GP and the medical practice retain a duty of care to the patient during this procedure”.
It underlines the vital importance of a patient removal being dealt with “sensitively and as sympathetically as possible.”
Situations that may justify removal of a patient include unacceptable behaviour such as physical violence, verbal or physical abuse, intentional damage to practice premises, sexual and racial harassment, stalking and inappropriate emotional attachment to the doctor. Another reason is crime and deception such as cases of patients fraudulently obtaining drugs, deliberately lying to the doctor or other member of the healthcare team and stealing from the practice premises or staff. A patient may also be removed if they have moved out of the designated practice area.
Except in extreme cases (such as those involving violence), removal should only be considered where the patient has persistently displayed unacceptable behaviour and should not be based on a single incident. Patients should not be removed from a practice list simply because they have made a complaint against the practice, for failing to comply with health advice or because they have a highly dependent condition or disability.
Where a doctor feels their relationship with a patient has irretrievably broken down, they must discuss it carefully with practice colleagues, inform the patient of the problem and consider meeting the patient to discuss the situation further. If all steps fail, inform the patient and your primary care trust/health board in writing of the decision and reason for removal and explain to the patient how to register with another practice. The patient’s family should not be automatically removed, nor should a patient be removed due to the actions of their relatives.
It is important to thoroughly document the incident or incidents that have led to a removal as well as any discussions with practice colleagues and communication with the patient. This will provide valuable evidence in the event of a patient complaint. The documentation should be kept in a separate file as it does not form part of the clinical records, and should not be passed to the new practice.
Dentists should also be mindful of the process involved in removing a patient from their practice list. In Scotland, practitioners should submit a GP200 form to their NHS board, stating the reasons for the request. The patient is entitled to a three-month notice period that their NHS registration is being withdrawn during which the dentist must provide emergency care. There are some circumstances where this can be done without a notification period. Once the NHS board has approved the request, the patient will be withdrawn from the practice list.
In England and Wales the situation differs slightly. Dentists seeking to remove a patient should complete a course of treatment (unless in extreme circumstances, such as violent patients) and if a patient is not currently under treatment, the dentist can simply end the relationship by offering no further treatments. The patient and the PCT should both be notified of the decision.
ACTION: Always follow guidance and be prepared to justify your decision to remove a patient from your practice list.