Following publication of the Ombudsman's report in 1999, the removal of patients from GPs' lists attracted considerable publicity, with two GPs being hauled before the House of Commons Health Select Committee to account for their actions.
The regulations are absolutely clear:
'A doctor may have any person removed from his list and shall notify the FHSA in writing that he wishes to have the person removed from his list and the removal shall take effect on the date on which the person is accepted by or assigned to another doctor or on the eighth day after the FHSA receives the notice, whichever is the sooner.'
The only caveat is where the patient requires treatment more frequently than every 7 days, in which case the removal takes effect after the patient no longer needs such treatment or when the patient moves to another doctor's list.
Removal of a patient from a doctor's list may be immediate where the patient has committed an act of violence against the doctor or made the doctor fear for his safety, and where the incident has been reported to the police.
In the two Ombudsman's cases, there was no suggestion that the doctors had failed to comply with the regulations in any way, so why did they come in for such criticism?
In the first case, the GP had seen the patient with a history of a flu-like illness for which he had been taking paracetamol. The doctor recommended that he continue with the paracetamol, but the patient asked for antibiotics. The GP said that he explained that antibiotics were unnecessary and gave a prescription for ibuprofen.
An hour after that consultation, the patient phoned the surgery saying that the medication he had been given would not work. He returned to the surgery and was seen again by the doctor, who again explained that antibiotics were unnecessary.
In the face of the patient's insistence the GP said that the patient had better find himself another doctor, to which the patient said "Just like that?" and the doctor replied "Yes, in fact I'll write to the Health Board."
In his report, the Ombudsman stated that a GP is entitled to remove a patient from his list and that there is no contractual obligation to give prior notice or reasons.
However, the Ombudsman's analysis of such cases is not confined to the doctor's obligations under the regulations. His remit in investigating a complaint is to consider whether the doctor's actions have caused hardship or injustice to the complainant.
The Ombudsman stated that he took the view that, as providers of a public service, GPs within the NHS implicitly accept an obligation to observe certain standards. He went on to say:
"Removal of a patient from a GP's list is a serious matter. He looks to see whether the GP has exercised his right to remove a patient reasonably and responsibly; and one aspect of that would be whether the GP had acted precipitately or disproportionately."
The Ombudsman came to the conclusion that the GP had acted precipitately in removing Mr A from the list without further discussion or considering alternatives. He said that it would have been reasonable to conclude the meeting by telling him that he could change doctors if he would not accept his advice, or at least to have allowed a 'cooling off' period to consider options before taking a final Eecision. And on that basis, the complaint against the GP was upheld.
In the second case, the parents of a patient who had made a complaint were removed from the doctor's list without any prior warning. The Ombudsman's report records the facts as follows.
Mr and Mrs Q, who lived in a different street from Mrs P (their daughter), said that they were shocked when they received a letter from the health authority telling them that they were to be removed from the doctor's list. They had experienced no problems in their relationship with the doctor, nor had they ever complained about him or any other GP at the practice. They had been with the practice for more than 40 years and on the doctor's list for a few years. They did not think that their daughter's complaint should have affected them in any way.
Mrs Q had seen the doctor regularly because of her diabetes and high blood pressure. Mr Q said he had seen the doctor on only one occasion, a home visit, but had attended the practice once or twice a year for check-ups in connection with a heart condition.
Having been removed from the doctor's list they had now registered with a new GP and did not wish to return to the doctor.
The partnership conceded that the decision to remove Mr and Mrs Q from the list was a direct consequence of the complaint their daughter had made about the management of another member of the family.
The Ombudsman found that the GPs believed that the daughter would eventually become involved in her parents' care and would complain unreasonably about that.
The Ombudsman stated in his report:
'I note with grave concern the comment made to me by the practice that they had told Mrs P that she and her family would be removed from the list if they complained. That certainly is neither in the spirit of the NHS complaints procedure nor in line with guidance from the General Medical Council.'
That last comment was based upon the section within Good Medical Practice 'When Things Go Wrong'.1 The Council requires doctors to 'respond to criticisms and complaints constructively'.
In addition to the GMC guidance, both the Royal College of General Practitioners and the then General Medical Service Committee (GMSC, now General Practitioners Committee) have issued guidance to doctors.
The GMSC stated that the removal of patients from GPs' lists should continue to be an exceptional and rare event and a last resort in an impaired doctor/patient relationship.
As far as other members of the household are concerned, the guidance went on:
'If the behaviour of one member of a household or family has led to their removal, GPs will need to use their judgment about other members. Sometimes an explicit discussion with other family members about the problem and the choices which they have will be helpful.
'In many cases, however, because of the duty to visit patients at home, it may be prudent to terminate responsibility for the entire household or other members of the family.'
Again, the GMSC would suggest that reasons are given.
In January 1997, the Royal College of General Practitioners issued Removal of Patients from GPs' Lists