The nGMS contract sets out the procedure for removing patients from the list under different circumstances, as Dr Gerard Panting explains
Removing patients from the list has always been an emotive issue, generating criticism from the Ombudsman, the press and even parliament. However, not all patients behave as they should, so when the new GP contract was introduced, some provision for the rude and unruly was required.
The new regulations governing removal from the list are lengthy and convoluted.1 In essence, there is one set of rules for people who have been violent or threatening, and another for all other circumstances.
Standard procedure for patient removal
To remove a patient from a list there must be reasonable grounds that cannot relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.
The first step is for the doctor to notify the PCT that he or she wishes the patient to be removed. The doctor must also notify the patient of the particular reasons for requesting removal. However, if it is inappropriate to be specific, and there has been an irrevocable breakdown in the doctor-patient relationship, a simple statement that the relationship has broken down irretrievably can constitute reason for removal.
There are further caveats. A doctor can only request a removal if, during the previous 12 months, the patient has been warned that he or she is at risk of removal for the reasons set out.
There are exceptions and removal without warning can occur in certain circumstances, such as if the patient has changed address. Another exception is if the doctor has reasonable grounds to believe that issuing a warning would be harmful to the physical or mental health of the patient, or that practice staff and attached personnel may be put at risk. A final exception is if "it is, in the opinion of the contractor, not otherwise reasonable or practical for a warning to be given.”1
Reasonable lack of warning
So what does ‘not otherwise reasonable’ mean in practice? Previous health service guidance published in December 1998, gave the Ombudsman’s view that there will be some circumstances in which removal without explanation is justified.2 However, the normal expectation is for the GP to follow good professional practice (recommended by the General Practitioners Committee of the BMA, the Royal College of General Practitioners and the General Medical Council), and explain the decision.
The Ombudsman has also stated that for the complaints system to work properly, it is essential that patients are not deterred from complaining, for fear that they might be ‘struck off’ the list. Therefore removal simply because a complaint has been made is unwarranted.
The Ombudsman has published cases that illustrate the interpretation of reasonableness. In one, a male patient, who had developed an attachment to his female GP,was told that his behaviour had jeopardised the continuation of the doctor-patient relationship, and therefore, he had been removed from the list. The patient complained to the health authority and the Health Service Commissioner, who took the view that the explanation he had been given was perfectly reasonable.
In another case, a GP removed a patient from the list, following a complaint, on the grounds that he had lost the patient’s trust and believed that the patient would benefit from a new approach, from a different practice. The Ombudsman rejected the patient’s complaint of unreasonable removal, following advice that it was generally beneficial for a patient to join another practice in such circumstances.
A third case involved removal from the list after an incident with a receptionist, about which there were conflicting accounts. A meeting followed in which the GP discussed the patient’s complaint with him, and the practice manager then wrote to the patient explaining why the GP felt it was necessary to remove him from the list. The Ombudsman found that the practice had dealt appropriately with the complaint, and that an investigation would be unlikely to resolve the differences between the two accounts.
A practice must keep records of every step of the removal process. If a patient has been given a warning, the practice is required to record in writing the date of the warning and the reasons for the warning as explained to the patient. If it has been deemed inappropriate to issue a warning, the practice must record the reason for this. The practice must also keep a record of removals from the practice list, including the reason given to the patient, the circumstances, and where specific reasons are not given, why it was inappropriate to do so. These records must be made available to the PCT on request.
Removal takes effect on the eighth day after the PCT receives notification from the practice, or when the PCT is told that a patient is registered with another practice, whichever is the sooner. However, where patients require frequent treatment (at intervals of less than seven days), removal takes effect eight days after the PCT is notified by the practice that the patient no longer requires such frequent treatment.
Finally, it is up to the PCT to notify the patient and the practice that the necessary paperwork has been completed, and that the patient is no longer on the practice list.
Removal of violent and threatening patients
When it comes to violent patients, the regulations allow speedier resolution. Where patients have been violent to any member of practice staff or attached personnel, or been threatening to the point that there have been fears for personal safety, the incident should be reported to the police immediately.
Reporting the incident to the police opens the door to fast track removal. Removal takes effect when the practice contacts the PCT via any means. Unless written notification is given, it must be confirmed in writing, within seven days. Faxed notification is not accepted as written confirmation.
Even under these circumstances, there is an expectation on the practice to inform the patient, unless it is not reasonably practical. Similarly, if there are reasonable grounds to believe that notification would be harmful to the physical or mental health of the patient, or put practice staff or other patients at risk, it is not necessary for the practice to notify the patient. In any event, the PCT has a responsibility to inform the patient.
Where patients are removed for threatening or violent behaviour, the practice is required to record in the patient records that he or she has been removed (under paragraph 21 of the regulations) and set out the circumstances leading to removal.
Removal of patients from the practice list is a last resort and frequently leads to complaints. If challenged, the practice must be able to justify the action as fair and reasonable – this might not stop the struck off patient from complaining, but should prevent complaints from being upheld.
- http://www.ombudsman.org.uk/about_us/ FOI/whats_available/documents/procedural/re moval_gp_lists.html
- http://www.ombudsman.org.uk/about_us/ FOI/whats_available/documents/procedural/re moval_98.html#egreject