Removing a patient is often the culmination of a series of misunderstandings and difficulties which cause the practice to feel the doctor/patient relationship cannot be salvaged. But practices should approach with caution because taking this step could cause further ramifications.
The MDU consistently receives queries from members about removing a patient from a practice list. In the five years to September 2017, we helped members with over 700 cases about this issue.
Although many were queries about whether a patient could be justifiably removed, a significant proportion were from GPs and practice managers asking for help with a complaint following the patient's removal.
As many practices have discovered, complaints are far more difficult to resolve when feelings are running high. This makes it far more likely that the complainant will take their case to the next level. Several cases involved Ombudsman investigations, and in eight cases, the patient had complained to the GMC.
The MDU is also aware of aggrieved ex-patients complaining about their treatment on social media or contacting the local newspaper, with potentially damaging consequences for the practice's reputation.
In short, removing patients is never an easy option for practices, although it can be justified in some cases. If you are considering removal, the MDU has produced the following guidance to help avoid the pitfalls.
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, 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.
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
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 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 patients concerned, this does not mean that their family 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.
7. Seek advice
If you are unsure of how to proceed in a particular case, contact your medical defence organisation for advice.