Last resort

MOST practice managers will have at some time faced the prospect of removing a patient from the practice list. In many cases the rationale is obvious and clear cut, for example when a patient no longer lives within the boundaries of the practice. Sometimes it may be for more fraught reasons such as when a patient has become violent towards a doctor or member of staff. But what about those patients who are continually rude to staff or who seem to complain perpetually about one issue after another?

MDDUS advisers frequently get calls from practice managers in regard to deregistering patients. Often the request has come from a doctor at the end of their tether with a patient’s unrelenting demands, or the practice staff is no longer willing to tolerate an individual’s bad behaviour at the reception desk.

Practices must act with care when considering removing a patient from the practice list. MDDUS has dealt with many cases where practices have faced censure for deregistering a patient without adequate warning. Complaints over removal not resolved at practice level can escalate to the ombudsman or a professional regulator who may levy criticism on practices or individuals for failing to follow contractual or professional requirements.

In 2011 former Parliamentary and Health Service Ombudsman Ann Abraham expressed concerns that “far too often” GPs don’t seem to be aware that their contracts require them to give a warning before a patient is removed “unless the circumstances are exceptional.” She said that in “far too many cases [what we see] is a knee-jerk response to a single incident where an individual – sometimes a whole family – is removed.”

Is removal justified?

A good starting point for any practice contemplating patient removal is a careful consideration of GMS contractual requirements. These stipulate that the patient should have had a warning in the previous 12 months about the situation or behaviour that the practice finds unacceptable, pointing out that the patient may be deregistered if this continues. The warning should offer the patient an opportunity to reflect on their actions and modify their behaviour. The GMS contract allows discretion to remove a patient without warning if a practice has a genuine belief that the issuing of such a warning would be harmful to the physical or mental health of the patient, or might put at risk the safety of the doctor or practice staff.

In the circumstance of aggressive or other unacceptable behaviour it would be reasonable to provide the patient with a formal warning in the form of a letter. The letter should advise the patient of the issues that have led to an erosion of the patient-practice relationship and should draw attention to the particular behaviour in question and in a manner that offers an opportunity to change that behaviour. The warning letter should detail what is expected from the patient, as well as any boundaries the practice might wish to implement in order to improve the situation.

Except in extreme cases (such as those involving violence), removal should only be considered where the patient has persistently displayed unacceptable behaviour and should not be based on a single incident. Patients should not be removed from a practice list simply because they have made a complaint against the practice, for failing to comply with health advice or because they have a highly dependent condition or disability.

The GMS contract has separate provisions for the immediate removal of violent patients, but in these circumstances it is expected that the police would have been informed of the incident. As well as their contractual requirements, practice managers should also be mindful of professional guidance offered to doctors by the General Medical Council. In the document, Ending your professional relationship with a patient, the GMC stipulates that:

• Deregistration should be a rare event prompted for example by the patient being threatening, abusive or violent, persistently acting inconsiderately or unreasonably, stealing from the premises or making sexual advances towards a member of staff. Patients should not be deregistered 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 that you are considering ending the relationship.

• When the decision has been made, the reasons should be explained to the patient in writing.

• When documenting the circumstances into the patient’s records, the entries should be factual and not written in a way that may unfairly prejudice future care.

The GMC also states that you must make prompt arrangements to ensure the continuing care of the patient and pass on the patient’s records to a new practice without delay.

Mediation first

One key element in all the guidance dealing with the breakdown in the practice-patient relationship is the need for a genuine attempt to resolve any issue that may have led to the impasse – to avoid that “knee jerk” reaction to “difficult” patients. The NHS Choices website informs patients: “you have the right to complain, have your complaint investigated, and be given a full and prompt reply.” Not only this but patients have the right to expect that making a complaint will not prejudice their ongoing care.

Our advice to practices in dealing with “difficult” patients is first to open a dialogue. Invite the patient to attend the practice for a discussion and try to get at the root of the problem. Sometimes there may be some underlying issue, such as a previous grievance. It may not even have to do with the patient themselves but with a family member. Some patients may also have unreal expectations of the service you are providing – for example that care should always be offered by a doctor rather than a practice nurse.

You should also consider the patient’s personal circumstances, bearing in mind any known physical or mental health conditions that may explain the reason for the difficult behaviour. Have they suffered a recent bereavement or job loss or marital breakdown?

To avoid charges of prejudicial treatment it is important to demonstrate you tried to mediate and resolve the breakdown in the relationship with the patient. There should be some discussion of possible ways of moving forward constructively and these discussions should be documented before making any decision to deregister.

Other alternatives to removal should be considered such as transferring the patient’s care to another partner (with the consent of both parties) or persuading the patient that it would be better for all concerned for he or she to attend another practice. In any case, it would be wise to get some advice before considering the deregistration of any patient and remember that MDDUS advisers are on hand to discuss such matters.

Scott Obrzud is an MDDUS practice adviser and co-editor of Practice Manager

Further resources

• British Medical Association – General Practitioners Committee (GPC) Removal of patients from GP lists

• Department of Health - Health service circular 2000/001 Tackling violence towards GPs and their staff

• General Medical Council - Ending your professional relationship with a patient (2013)