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A quick guide to de-registering patients

The problem

This month I received a call from Dr Smith about his patient, Mrs A, and her sons. Dr Smith described Mrs A as a particularly demanding patient who regularly complains about his treatment of her. Although her sons are not so bad, Dr Smith said he did not want to deal with any member of the family anymore. 

When he returned to work after Christmas, Dr Smith decided to remove Mrs A and her sons from his list but sought legal advice first.

I explained to Dr Smith that removing patients from practice lists is a tricky issue and one which could leave him exposed to complaints to the Health Service Ombudsman, GMC or PCT. The Ombudsman has recently highlighted her ‘concerns about GPs striking patients off their lists unfairly’ and 21% of all GP complaints investigated by them last year related to patients being removed from their GP’s list. 

I explained the key provisions about removing patients (which could be found at clauses 192 – 229 of Dr Smith’s GMS contract). 

The key points are:

  • You must have reasonable grounds for wishing to remove the patient.
  • Your grounds must not relate to the patient’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.
  • You must notify the PCT and the patient in writing about the removal and give the patient specific reasons for it.
  • If it would not be appropriate to provide specific reasons to the patient, you may simply state that there has been an irrevocable breakdown in the doctor-patient relationship.
  • You may only request a removal if, during the preceding 12 months, you have warned the patient that they are at risk of removal and explained the reasons why.
  • This requirement to issue a warning is only waived if you reasonably believe that issuing such a warning would be harmful to the physical or mental health of the patient, or would risk the safety of someone who works at or owns the practice.
  • You must keep a written record of the patient’s removal, the reasons behind it and the date on which the prior warning was issued.
  • You can only remove without issuing a prior warning if a patient has been violent and you have reported the matter to the police or it is, in your opinion, not otherwise reasonable or practical for a warning to be given.

Unfortunately, I had to advise Dr Smith that Mrs A being demanding and a frequent complainer was unlikely to constitute reasonable grounds for removing her.  Indeed, Good Medical Practice specifically states that you “should not end a relationship with a patient solely because of a complaint the patient has made about you”. Similarly, the BMA has stated that it neither “supports nor condones the removal of patients because they have made a complaint”.

I also advised Dr Smith that, if he removed Mrs A’s sons solely because of her behaviour, this was very likely to constitute an unreasonable removal. In a number of similar cases the Ombudsman has ordered GP practices to apologise to the de-registered family members and pay compensation. In general, it will only be reasonable to remove a patient’s family members as well as the patient where the patient has been violent and it would be difficult to treat the family members without the presence of the violent patient (for example, because the violent patient is a carer to their family members). 

Action plan

In the circumstances, I suggested to Dr Smith that he: 

  • Review whether there is any truth to Mrs A’s complaints, or anything in the practice which may be contributing to her demanding behaviour. For example, does his receptionist have poor interpersonal skills? Is it very difficult to access appointments? Is he over-worked or stressed?
  • Consider the reasons behind Mrs A’s behaviour if her complaints are groundless. Could mental health difficulties, language barriers or cultural differences be relevant?
  • Implement strategies to address any issues identified. For example, additional training for the reception staff or the offer of an interpreter.
  • Maintain detailed records of relevant incidents and issue a warning prior to considering Mrs A’s removal again (if matters do not improve once he has taken the steps above).  
  • Consider whether Mrs A could be seen by Dr Jones or another doctor in the practice, if Dr Smith feels his relationship with her has irretrievably broken down. 
  • Remember that removal is a remedy of last resort and can give rise to a whole new set of problems for the practice.

Andrea James is head of healthcare regulatory at George Davies Solicitors LLP, a former in-house solicitor to the General Medical Council and specialises in advising doctors.