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How to…remove ‘difficult' patients from the list

Beware the pitfalls when the doctor-patient relationship fails, warns the MDU's Emma Cuzner

Removing patients from the practice list when a relationship has irretrievably broken down or when a patient has been violent in the surgery can be fraught with difficulties and is a common cause of complaints.

Warn the patient

Practices are contractually obliged to have given the patient a warning that they are at risk of removal in the preceding 12 months to any removal and to have explained the reasons.

In some cases, it may be appropriate to arrange a meeting with the patient to find out whether there are any problems that need to be addressed. This might even lead to restoration of mutual trust and respect, and the issue can be closed.

The RCGP has published advice on steps, short of removal from the list, that may help to restore the doctor-patient relationship.

It is advisable to document all the steps you have taken to resolve the situation.

Justify your decision

Beware of removing patients who are ‘difficult' because, for example, they have missed appointments or even made complaints about the practice. This may not be justifiable and may prompt a further complaint.

The GMC in ‘Good Medical Practice' advises that doctors must be satisfied that their decision to end a professional relationship is fair and not influenced by a ‘patient's age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status'.

Resources should not be considered

GPs should not remove a patient solely because of the resource implications of the patient's care. If a patient is removed, this does not mean that the patient's family should automatically be removed too. Any removal must be carried out in line with the practice's contractual arrangements. See paragraphs 20 and 21 of Schedule 6 of the National Health Service (General Medical Services Contracts) Regulations 2004 (or the equivalent PMS requirements).

If you believe that removing the patient is the only option, inform the patient and the primary care organisation (PCO) in writing, of your decision and the reasons for removal.

GPs may wish to reassure patients that they will not be left without a doctor and to give them information on how to register with another practice.

Report violent patients

If you need to remove a patient who has been violent from the list with immediate effect, you should first report the incident to the police, who will give you an incident number, before notifying the PCO. The removal takes place immediately after the PCO has been informed. You can do this by telephone or fax, but in both of these cases, it is essential that you follow it up in writing within seven days of the initial notification. The PCO will then arrange continuing care for the patient.

Under the GMS contract, the practice is required to inform the patient that they have been removed, unless this is not practical or there are reasonable grounds to believe this would be unsafe. Making an entry in the clinical record that the patient has been removed under the violent patient provisions and the circumstances leading to this may be prudent.

  • A GP contacted the MDU to ask for advice about a patient she wanted to remove from the list. The patient was a frequent visitor to the surgery, although she regularly missed follow-up appointments. Most recently, she had complained about the GP's refusal to make a home visit while she was recovering from viral gastroenteritis.
  • An MDU medico-legal adviser told the GP that while the patient's behaviour was certainly disruptive, the removal of a patient around the time of a complaint was contrary to GMC guidance and might in itself provoke a further complaint. The MDU adviser suggested that she consider inviting the patient into the surgery for a meeting during which she could explain the nature and limits of the practice's services and find out if the patient had any underlying problems. She could additionally consider sending the patient a letter of warning.
  • If, at some future point (and after a warning had been issued) the GP still felt that the relationship had irretrievably broken down, she may then be in a position to justify taking the appropriate steps to remove the patient. However, in doing so, she would need to act in accordance with her contractual obligations and GMC guidance and be able to justify her decision.

This is a fictitious case study based on cases from the MDU's files. GPs with specific concerns are advised to contact their medical defence organisation.

- Emma Cuzner is a medico-legal adviser with the Medical Defence Union, www.the-mdu.co.uk


National Health Service (General Medical Services Contracts) Regulations 2004.

Removal of Patients from GPs' Lists: revised guidance for college members', RCGP, September 2004.

Good Medical Practice, GMC, October 2006.

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