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ADVICE  DEREGISTERING PATIENTS


Removing a troublesome patient from the practice list is rarely an easy option. PM editor Scott Obrzud urges caution


Last resort M


OST 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 pa- tient’s unrelenting demands, or the practice staff is no longer willing to tolerate an indi- vidual’s bad behaviour at the reception desk. Practices must act with care when consid-


ering 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. Com- plaints 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


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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 contem- plating patient removal is a careful considera- tion 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 oppor- tunity to reflect on their actions and modify their behaviour. The GMS contract allows discretion to remove a patient without warn- ing 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 reason- able 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 man- ner 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 require- ments, practice managers should also be mindful of professional guidance offered to doctors by the General Medical Council. In the document, Ending your professional relation- ship with a patient, the GMC stipulates that: • Deregistration should be a rare event


SUMMER 2014  ISSUE 10


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