INTRODUCTION
There may be circumstances when it would be considered reasonable, or in the best interests of the patient, to remove patients from the list.
The purpose of this policy, therefore, is to define the practice guidelines for removal of a patient from the practice list and to ensure that any concerns about removing patients from the list are dealt with fairly.
SITUATIONS WHICH JUSTIFY REMOVAL
Violence
When a patient:-
- Is physically violent or threatening towards a doctor, practice staff or other patients on the practice premises.
- Causes physical damage to practice premises or other patient’s property.
- Gives verbal abuse or makes threats towards the doctor, practice staff or other patients.
- Gives racist abuse, orally or physically.
- Is violent or uses or condones threatening behaviour to doctors (or some other members of the primary health care team) while visiting the patient’s home. Such behaviour may involve the patient, a relative, a household member, or pets (such as unchained dogs).
Crime & Deception
Where a patient:-
- Fraudulently obtains drugs for non-medical reasons.
- Deliberately lies to the doctor or other member of the primary health care team (e.g. by giving a false name or false medical history) in order to obtain a service or benefit by deception.
- Attempts to use the doctor to conceal or aid any criminal activity.
- Steals from practice premises.
Distance
- Where a patient has moved out of the designated practice area and has failed to re-register with another GP.
Embarkation
- Where a patient has moved abroad for a period of 3 months or more.
- Failure to attend pre-booked appointments.
- Where a patient fails to attend pre-booked appointments on a number of occasions during a given period.
- Irretrievable breakdown of the Doctor/Nurse-Patient relationship.
- Where a patients behaviour falls outside of that which is normally considered reasonable and leads to an irretrievable breakdown of the doctor-patient relationship
PROCEDURE FOR REMOVAL
Violence / Crime and Deception
Any incident involving violence, crime or deception will be immediately reported to the Management Team, who will complete an incident report and bring to the attention of the practice partners. Staff involved should also make a written statement at the time as further evidence. It may be so serious that the police may need to be contacted.
If it is that serious then the patient can be removed immediately by contacting the Commissioning Group / Registration Department advising them of the incident and giving them a log number that the police have given.
For less serious matters.
Each case will be discussed with all involved in the surgery and a partner. A majority agreement will be reached. If it is to remove the patient it can be done under the 8 day rule.
The Commissioning Group and Registration Department will need to be contacted and a brief outline given.
Following that agreement, the Management Team will write to the patient and explain the reasons for removal.
The Registration Department should then deduct the patient in the normal way.
Distance
On notification that the patient is no longer living within the practice boundary, a letter will be sent to the patient advising of the need to re-register within 28 days elsewhere
Notification will be sent to the Registration Department after 28 days if the patient has not been deducted by the Registration Department as they have not registered elsewhere
Embarkation
On notification that the patient has moved abroad the patient will be removed from the Practice list within 3 months of that notification.
Failure to attend pre-booked appointments
If a patient continually fails to attend pre-booked appointments, they will be reviewed and if deemed necessary a warning letter will be sent to the patient, advising them that a further occurrence could risk removal from the practice.
Warning letters are valid for a period of 12 months. Removal based on warnings greater than 12 months old will be invalid – in this case a further formal warning and period of grace will be required.
If the patient fails to attend another appointment, the matter will be discussed at a practice meeting and a majority agreement will be reached as to whether the patient will be removed from the practice list.
Following agreement the Management Team will write to the patient and explain the reasons for removal.
Guidance on removing patients due to irretrievable breakdown of the doctor – patient relationship.
Occasionally patients persistently act inconsiderately and their behaviour falls outside that which is normally considered to be reasonable. In such circumstances there may be a complete breakdown in the doctor-patient relationship.
Steps to be taken within the Practice
- Inform all appropriate members of the practice about the problem.
- The patient and possible reasons for the patient’s behaviour (e.g. disagreeableness, cultural differences, mental illness, and personality disorder) will be discussed at a practice meeting.
Steps to be taken with the patient
- Inform the patient, either personally or in writing, that there is a problem.
- Explain the nature of the problem to the patient.
- Obtain the patient’s perspective and interpretation of the situation.
- Obtain advice of a Medical Defence Organisation.
Steps to be taken if discussion fails to resolve the problem
- Suggest that another GP within the practice might better fit with the patient’s needs and expectations.
- Steps to be taken in actually removing the patient.
- Inform the appropriate Registration Department in writing of your decision.
- Inform the patient in writing of the decision and the reason for removal from the list.
- Explain to the patient that he or she will not be left without a GP.
- Give the patient information on how to begin the process of registering with another GP.
Family Members
When a decision is made to remove a patient from the practice list, the removal may well be extended to other members of the family or household. Removing other members of the household
If the behaviour of one member of a household or family has led to their removal, this does not mean that the removal of other family members should automatically follow. An explicit discussion, whilst protecting the confidentially of the removed patient, with other family members about the problem and the doctor’s concerns will often obviate the need for any further action.
In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family.
This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members could put doctors or their staff at risk.
The practice should always consider how it would look to outside observers if a family were to be summarily removed from the list, in haste, without explanation for a single misdemeanour or disagreement with one family member.
The Management Team will write to the family / household offering an explanation for the removal. They will be allowed 4 weeks to re-register rather than being removed from the practice list immediately.
Responsibility
Responsibility for implementing and monitoring the policy rests with the Practice Partners / Management Team.
The practice re-affirm its commitment to do everything possible to protect staff, patients and visitors from unacceptable behaviour and their zero tolerance of any incident that causes hurt, alarm damage or distress.