With higher patient expectations and general practice being under more pressure it’s not surprising that the doctor/patient relationship can be put under strain sometimes.
With good communication and understanding from both sides, difficulties can generally be resolved to everyone’s satisfaction. However, sometimes the practice may feel that the doctor/patient relationship has reached a point where it can no longer be salvaged.
Caution needs to be taken, however, if practices are considering removing a patient from their list.
The MDU consistently receives requests for advice and assistance from members about removing a patient from the practice list. In 2022 alone, we helped members with over 130 cases about this issue.
Before you remove a patient from your list
Before removing a patient from the practice list, it is important to take into account a number of considerations, particularly if a patient has already made a complaint prior to the decision to remove them. It is not uncommon for patients to escalate ongoing complaints to the Ombudsman if they are subsequently removed and, therefore, being able to justify the decision is of paramount importance.
Patients may also complain after they have been removed and this may, again, end up in the hands of the Ombudsman. Although less common, patients may decide to complain to the GMC if they feel a particular doctor has treated them unfairly.
As well as making a formal complaint under the NHS complaints procedure, the MDU is also aware of patients taking to social media or contacting local media outlets, with potentially damaging consequences for the practice’s reputation.
As well as making a complaint, rarely, patients may also pursue legal channels, to try to take action against a practice that makes a decision to de-register them as a patient. The MDU has recently successfully defended a practice against a discrimination claim made by an abusive patient brought under the Equality Act 2010. This patient had acted in an aggressive and intimidating way causing staff to feel threatened. The judge found that it was necessary, in this case, to remove the patient to protect frontline staff from abuse.
If you have reached a point where you are considering removing a patient from the practice list, the MDU has produced the following guidance to help avoid the pitfalls which could otherwise lead to criticism.
1.Be able to justify your decision
The GMC says doctors must be satisfied their reason for wanting to end the relationship is fair and does not discriminate against the patient. Examples of behaviour that might justify removal include violence or threats, theft from the practice or staff, being persistently inconsiderate or unreasonable; or making sexual advances. It stresses that patients should not be removed solely because of a complaint or because of the resource implications of their care or treatment.
2. Warn the patient about their behaviour
Unless the patient has been violent or committed a crime, you would usually be expected to warn them, usually in the preceding 12 months, that they risk removal from the practice if they don’t change their behaviour.
If you can, take this opportunity to find out what might lie behind their actions. For example, disruptive or aggressive behaviour might be related to the patient’s condition, anxiety or frustration and could be addressed with additional support. Keep a record of your discussion with the patient and follow up your warning in writing, explaining what the concerns are about the way they are behaving and the impact this is having.
3. Inform the primary care organisation
If the problems continue and you believe you cannot provide good clinical care to the patient because of the breakdown of trust, you should follow local procedures for removing the patient.
In England, this means you should write to the patient, informing them of your decision and the reasons and explaining that arrangements will be made for their continuing care (including providing necessary care until the patient registers with a new practice).
You must also notify the local area team in writing of your decision and the reasons (in Scotland and Wales, notification would be to the local health board). The area team or health board can help patients register with a new practice.
4. Violent patients
In a study from the MDU journal of violent incidents reported by members, of the primary care staff who seek our advice each year, the most common query is about removing patients from the practice list. Sadly eight in 10 GP members responding to an MDU survey reported increasing levels of abuse from patients or those representing them.
If a patient has been violent or abusive, or has behaved in a threatening way, you can remove them immediately, provided you have reported the incident to the police and obtained an incident number. If information needs to be disclosed to the police, it should be the minimum necessary to allow for a proper investigation and will rarely require disclosure of medical information.
You still need to notify the area team or health board in writing, either immediately or within seven days in order to comply with contractual commitments. When a patient has been violent, it may be unsafe or impracticable to have further contact. Speak to your area team or health board if this is the case.
5. Don’t remove other family members
Even if you eventually decide to remove the patient concerned, this does not mean that their family, including young children, should automatically be removed too. It may be hard to justify the removal of patients whose behaviour has not directly led to problems.
6. Keep detailed records
Keep clear and detailed notes of any incidents that have led to the removal (including statements from relevant staff members); any steps that have been taken to resolve the situation; the specific reasons for the removal and the process of removal that was followed.
These will be invaluable if you are called upon to explain or justify your decision, for example if the patient makes a complaint or decided to take legal action. As with complaints and other non-clinical correspondence, these notes should be kept in a separate file to the patient’s clinical records, unless the information is clinically relevant to their care.
7. Seek advice
It is better to seek advice early, preferably before the decision is made to remove a patient. If you are unsure of how to proceed in a particular case, contact your medical defence organisation.