Patient removal

The aim of this guidance is to help practices undertake removals fairly and in line with the Standard General Medical Services Contract, NHSE England, BMA and PCSE Guidance (links provided in footer).

Breakdown in relationship

Removing a patient due to breakdown in relationship should be rare but can be very contentious. 

Practices must have reasonable grounds in which to removal a patient from their list which are not, in any way connected with age, gender, immigration status, class, religion, sexual orientation, disability, medical condition. 

In a scenario where a patient displays persistent inappropriate behaviour towards any practice staff which leads to breakdown in the relationship with the patient, practices can consider the removal of said patient.

All circumstances must be considered before reaching the decision to remove the patient.  Has the patient’s perspective been considered?  Is their condition a contributing factor to their behaviour? Could the situation have been handled better by the Practice? 

Patients may be removed from the practice list:

  • if they have received a warning that they are at risk of removal within the last 12 months (sample checklist for warning letter below) and;
  • when they have been provided with a reason for the removal.
Where the practice believes that it is not appropriate to give specific reasons, it is sufficient to state that there has been an irrevocable breakdown in the relationship between the practice and the patient.

A warning is not necessary when:

  • the removal is due to a change of address
  • the practice believes that the warning would harm the patient’s physical or mental health
  • the practice believes that issuing the warning would put the safety of members of the practice or those on the premises at risk
  • it is, in the GP’s opinion, not otherwise reasonable or practical for a warning to be given.
Care should be taken to ensure that the reasons given are factual, and that the tone of the letter is polite and suitably informative.  We would always suggest practices contact us for advice if they are considering removing a patient from their list.

Letters should include:

  • Name and role of person sending letter (we recommend that this is usually the Partners).
  • Brief description of the behaviour or incident.
  • Details of any previous steps taken to address the behaviour.
  • Say why the behaviour is unacceptable and the impact it has had on staff, other patients or NHS services.
  • Set out what will happen if behaviour is repeated (this may include de-registering the patient from the practice on the grounds of an irrevocable breakdown in the relationship should the unacceptable behaviour be repeated within the next 12 months, in line with the Standard General Medical Services Contract).
  • Say who will be informed or copied in (if applicable).
  • Advise that a record will be made of the incident (i.e. significant event log)
  • Give the patient the opportunity to respond, providing information on how decision may be challenged and details of the practice’s complaints process.

First Warning Letter

It is good practice to warn patient in writing as this allows for carefully considered reasons to be given.

Second Warning Letter

If after issuing the first warning letter, a repeated incident occurs in the next 12 months, practices can write to the patient a second time, in the same format as the first.  Practice can then apply to NHSE England to have the patient removed from the list under the 8-day removal criteria.

Sample wording for Zero Tolerance Statement

As a Practice we are very aware that visiting your GP can, at times, be stressful and concerning for patients. Delays in obtaining appointments and delays in surgery times, due to unforeseen emergency appointments, can also add to these concerns.

We always strive to meet patient expectation and deliver the highest standards of healthcare. For the vast majority of our patients, we achieve this, despite the finite resources and steadily increasing demand for services that exists today within the NHS.

Our staff come to work to care for others, and it is important for all members of the public and our staff to be treated with respect.

In line with the rest of the NHS and to ensure this is fully observed we have instigated a Dignity at Work and Zero Tolerance policy, whereby aggressive or violent behaviour towards our staff will not be tolerated under any circumstances.

Anyone patient who verbally abuses a member of practice staff will be sent a letter from the Practice confirming that this behaviour will not be tolerated. Any future violation of this policy may result in removal from the Practice patient list. The Police will be called in all cases of violence

The Practice feels sure you will understand that proper behaviour is absolutely necessary for our staff and patients and that non observance will not be accepted.

Violent Patients

When GP practices have a patient, who is violent or exhibiting behaviour that makes them fear for their safety, the patient should immediately be removed from the practice list.

The special allocation scheme provides primary care medical services in a secure environment to patients who meet the criteria.  Designated GP practices provide services to patients by appointment at specific locations and times as detailed in individually agreed contracts. Patients join the scheme after being immediately removed as a result of an incident that was reported to the police.

The purpose of the scheme is to deal with patients who are aggressive, abusive or violent. It aims to protect GPs, practice staff and patients who have the right to be in the practice without fear of intimidating behaviour.

Removal is appropriate when a practice has grounds to show that the individual committed an act of violence – or behaved in such a way that they feared for their safety. This could be against a doctor, partner, member of staff, visitor or patient on the premises.

There is no exhaustive list of behaviour and the practice’s judgement is necessarily subjective, but the main types of behaviour that would justify a patient’s immediate removal are:

  • assault
  • threatening behaviour
  • behaviour resulting in damage to property.

 The removal process:

  1. Call 999 or your local police station as soon as possible.
  1. State what happened and if necessary, request police assistance at the incident location. The police will allocate an incident number that can be requested by the practice.
  2. Notify NHS England at 0333 014 2884 or pcse.patientremovals@nhs.netThe removal takes effect at the time at which the practice contacts PCSE.
  3. Inform the patient of the removal, as long as it would not be harmful to the patient’s mental or physical health or put any of the people listed above at risk.
  4. Notify the CQC ‘without delay’, either while a registered activity is provided or as a consequence of it being provided, including incidents involving the police.

Process in reporting to PCSE:

PCSE must ensure the patient no longer remains on the practice list, but that they can continue to receive primary medical services through a commissioned SAS provider.

PCSE will write to the patient to tell them and should ensure a flag is placed on the patient record to stop them registering at another practice.

The removal of a patient and their allocation to the SAS remains under review by a panel.

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GMS Regulations: https://www.legislation.gov.uk/uksi/2015/1862/schedule/3/part/2/made

NHSE Guidance: https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/

PCSE Guidance: https://pcse.england.nhs.uk/help/registrations/patient-removals/

BMA Guidance: Removing-patients-from-your-practice-list and Removing-violent-patients-and-the-special-allocation-scheme

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