Removal of patients from the practice list

MDDUS receive regular calls from practices who are considering de-registering a patient. These advice requests are often from practice managers dealing with patients who repeatedly do not attend appointments or fail to follow clinical advice and engage with treatment. More seriously, some concerns are raised when patients have been threatening or behaved violently against practice staff. Each circumstance must be treated individually but here we offer some general advice.

Basic considerations

The GMS contract (both Scotland and England) stipulates that a patient must have received a warning in the 12 months prior to the practice taking action to de-register that individual. This warning must specify the unacceptable behaviour or situation and point out that de-registration is a likely outcome if that behaviour is repeated.

Exceptions to this are:

• The reason for removal relates to a change of address which falls outside of the practice catchment area.
• The contractor has reasonable grounds to believe that the issuing of such a warning would:  be harmful to the physical or mental health of the patient, or  put at risk the safety of the doctor or practice staff.
• There are also separate provisions to allow the immediate removal of violent patients, and in these circumstances it is expected that the police would have been informed at the time of the incident.

The GMC also provides useful guidance on ending a professional relationship with a patient. Before doing so, the following are important points to consider:

• De-registering a patient should be a rare event, prompted, for example, by the patient being threatening, abusive or violent, persistently acting inconsiderately or unreasonably. Patients should not be de-registered simply because they have made a complaint or a claim, or because their medical needs are burdensome.
• Every attempt should be made to restore the relationship or consider alternatives.
• A warning should be given.
• When the decision has been made to de-register a patient, the reasons should be explained to the patient in writing and recorded. An entry into the patient’s records should be made where clinically relevant only, be factual and not written in a way that may unfairly prejudice future care.

In all circumstances MDDUS advises that special discretion or allowance should be considered in the case of patients with behavioural difficulties as a result of mental illness, learning disability or other factors, especially if they do not have full capacity or insight.

MDDUS has also dealt with cases in which other family members of the patient to be de-registered have been removed from the practice list. This might be argued on safety grounds for clinicians and staff, but such a blanket decision is difficult to justify.

Persistent defaulters from appointments can have a significant resource impact on any practice and can be tricky to manage. However, it is important that practices engage with such patients. Any decision to remove them from the practice list would only be justified where a clear process has been followed and a written warning issued which stipulates the consequences of continued non-attendance. It is important to consider the impact of the patient’s health on the reasons for non-attendance.

Common pitfalls

• Removal of a patient from a practice list without a clear written warning concerning their unacceptable behaviour and providing an opportunity for the patient to change.
• Failure to follow due process with regard to requirements set out within the GMS contract or from professional regulators, such as the GMC.
• Arbitrary removal of other family members from practice lists following unacceptable behaviour by a patient.

Key points

• Take care to ensure that the decision to deregister a patient has been fully considered, documented and is fair.
• Failure to take account of professional guidelines and statutory contractual requirements can leave a provider open to criticism, investigation or other legal action.

Further guidance

• GMC - Ending your professional relationship with a patient
• National Health Service (General Medical Services Contracts) Regulations 2004
• National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 (Schedule 5, part 2, section 20 onwards)

MDDUS Training & CPD resources