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If removal is inevitable it is essential to do it sensitively and properly ­ Dr Nicholas Norwell of the MDU shows how

It is unusual for a doctor/ patient relationship to break down to such an extent that a practice considers removing the patient from its list, but it does happen. What should GPs bear in mind when dealing with this difficult issue?

In the light of the recent updated guidance from the RCGP1 on removing patients from their lists, some GPs may be rethinking their policy. Not all relationship breakdowns with patients can or should be salvaged, and removing a patient sometimes has to be the last resort.

We at the MDU know the act of removal can itself lead to a complaint, so it's vital to handle the removal sensitively and properly. Sometimes you can give the patient a warning to change their behaviour. If you do plan removal, tell them why and give them notice.

These actions can help avoid a complaint. In the majority of cases practices would also be expected to have given the patient a warning that they were at risk of removal in the preceding 12 months, under the terms of the new contract (clause 194).

The RCGP guidance suggests the practice considers a meeting with the patient and considers too if factors in the practice may be contributing to the problem. When removing patients from your list, have in mind clauses 192-201 and 202- 209 of the general medical services contract or primary medical services requirements. The MDU is able to help members at each step along this, at times, difficult way.

A recent study of patient removals by the University of Leicester found 'patients often appeared not to understand why they had been removed'. The survey, which questioned 204 GPs and 319 recently removed patients, found that although the doctors reported giving a reason in nearly 60 per cent of cases, only 36 per cent of patients agreed.

The researchers found little could be done to reduce the level of patient removals, as many were the result of violent or abusive behaviour, but concluded that better explanations would help patients realise why they had been removed and so avoid similar situations happening with their next GP.2

Justify your decision

The MDU has advised GPs for some time that they should be prepared to justify a decision to remove a patient from their list and, in most circumstances, patients should be given a written explanation for their removal and notice of it. The GMC, too, advises doctors to give an explanation ­ orally or in writing (Good Medical Practice paragraph 25).

GPs are obliged to inform their PCO of the decision and in most cases to tell the patient of the removal and the reasons for it in line with clauses 192-209 of the new contract. If violence is the reason for removal, the contract says the doctor shall record in the patient's notes that they have been removed under the appropriate paragraph. Also note the circumstances leading to the removal.

When removing a patient it should also be made clear that the patient will not be left without a GP, and the patient should be given information on how to begin the process of registering with another practice. The GMC advises that you make arrangements quickly for the continuing care of the patient and hand over records to the patient's new doctors as soon as possible.

Violence

There will be occasions where the doctor/patient relationship has broken down to such a degree that it is inappropriate to provide an explanation: for example when a practice needs to remove a patient immediately because they have been violent. In these cases, it is important to inform your PCO of the decision as soon as possible as the PCO will need to arrange continuing care for the patient.

If there is actual or threatened violence you can remove a patient with immediate effect provided the matter is reported to the police first, before notifying your PCO.

If disclosing information about a patient, without consent, to a third party, such as the police, the GMC recommends 'you should generally inform the patient before disclosing the information' (Confidentiality: Protecting and Providing Information, paragraph 27). The GMC recommends keeping disclosures to the minimum necessary (paragraph 1).

If a patient is not removed with

immediate effect, the usual seven-day notice period applies and the patient will be entitled to receive services from the practice during that period.

When removal is not appropriate

The RCGP says cases that do not normally justify removal include refusing to take part in a locally or nationally agreed screening programme, refusing to allow children to participate in immunisation campaigns, or failure to comply with health advice.

Remember that patients have a right to

give or withhold consent to treatment and should not be penalised for exercising that right.

While it may be justifiable to ask a patient to change practice if a complaint or litigation has led to a breakdown in the doctor-patient relationship, or if a complaint has been shown to be activated by malice, the GMC advises against removing patients solely because they have made a complaint.

The RCGP also advises against automatically removing a patient's family when you remove a patient.

You should be able to justify a decision to remove a patient from your list. Document in detail any incidents that lead to the removal, any steps taken to retrieve the situation, the specific reasons for the removal and the process of removal.

Seek advice ­ we at the MDU are always willing to help.

Case study: a happy outcome!

A patient called a receptionist a 'f***ing bitch' in front of a crowded waiting room when he could not obtain an immediate appointment to see a doctor. The practice wrote to him saying such behaviour would not be tolerated, inviting him to consider seeking medical advice elsewhere.

The practice met him. He said he had always had great faith in the doctors and regretted greatly what he said to the receptionist. He explained that his behaviour was uncharacteristic and that he had no wish to leave the list.

While explaining that he did not wish to excuse his behaviour, he said he was suffering from tonsillitis at the time of his outburst, something he had suffered from a few months earlier, and that he was hoping to get another prescription for the same antibiotic he had been treated with previously.

The practice explained that they had just started regular telephone consultation sessions which he may wish to access in future. He remained on the list, and was so impressed with the way the practice had handled the situation that he became an active fundraiser for equipment and was later elected chair of the practice patient group.

Remember

Don't

·Act impulsively

·Remove patients simply because they've made a complaint

·Automatically remove the family

Do

·Consider each step

·Consider meeting with the patient

·Put things in writing

·Seek advice from your medical defence organisation

References

1 Removal of patients from GPs' lists: revised guidance for college members, RCGP, September 2004 www.rcgp.org.uk/

2 Ending the doctor-patient relationship in general practice: a proposed model, Tim Stokes et al, University of Leicester, Family Practice: 21 (5) October, 2004

www.fampra.oupjournals.org/current.shtml

Nicholas Norwell is a medicolegal adviser at the MDU

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