Removal of patient from GP registered list

The main pathways for a general practice to remove a patient from its registered list are summarised as a flow chart in Annex A.

The number in each section refers to Schedule 3 of the National Health Service (General Medical Services Contracts) Regulations 2015 as amended . There are equivalent paragraphs in the Primary Medical Services regulations. Alternative Providers of Medical Services (APMS) contracts are individual but are likely to include the same clauses.

1. Removal on reasonable grounds
2. Removal of violent patient
3. Removal of patient registered elsewhere
4. Removal of patient who has moved out of practice area
5. Removal of patient whose address is unknown
6. Removal of patients for other reasons 

The LMC has developed guidance to support practices, if this is an action required but this should be carefully considered and used as a last resort when all other avenues have been explored.

• Click to read our full guidance and annex one

Difficult Patients

The LMC is frequently asked for advice regarding patients whose behaviour is causing significant difficulties for practices. This can include patients who:

• Request an excessive number of appointments or contacts.
• Refuse to see anyone other than a specific clinician.
• Submit repeated, vexatious or unreasonable complaints.
• Display racist, discriminatory, threatening or abusive behaviour towards staff or other patients.
• Repeatedly fail to engage with reasonable practice processes and policies.

Managing these situations can be challenging. Practices should seek to maintain a therapeutic relationship wherever possible whilst ensuring the safety and wellbeing of staff and other patients, and preserving the effective operation of the service.

In general, there are two options:

1. Continue working with the patient whilst taking steps to address and modify the problematic behaviour.
2. Consider removal from the practice list if there has been an irretrievable breakdown in the doctor-patient relationship or where behaviour is sufficiently serious. Please see our separate guidance on patient removals.

Behaviour Contracts

Where a practice wishes to continue the patient relationship, a Behaviour Contract can be a useful and proportionate intervention. Behaviour Contracts are an established approach and can help set out clear expectations regarding future conduct, the standards of behaviour expected by the practice, and the consequences of failing to meet those standards. Behaviour Contract template can be found here.

NHS England provides a Behaviour Contract template which practices may adapt to meet local circumstances. Any template should be amended to reflect the specific behaviours the practice is seeking to address.

The LMC recommends considering the following wording within Behaviour Contracts.

Replace:

“Any patients who commit any inappropriate or unacceptable behaviours towards a GP, Practice staff, other patients or the surgery premises or property risk being removed from the practice list with 8-days’ notice. We will normally provide a warning letter which will be held on record for 12 months before issuing such a notice.”

With:

“The practice will consider removing you from the practice list if you commit any inappropriate or unacceptable behaviours, including any of those set out in this document, towards a GP, Practice staff, other patients or the surgery premises or property, with 8-days’ notice, and this document acts as a formal warning letter for this purpose.”

This wording provides greater clarity that the Behaviour Contract itself constitutes a formal warning and ensures the patient is fully aware of the potential consequences of further unacceptable conduct.

Good Practice Points

When managing difficult patient situations, practices should:

• Maintain clear, contemporaneous records of incidents and communications.
• Ensure all correspondence remains objective and factual.
• Consider whether behaviour may be influenced by underlying health, mental health or safeguarding issues.
• Apply policies consistently and fairly.
• Support staff who have been subjected to abusive, discriminatory or threatening behaviour.
• Seek advice from the LMC, medical defence organisation or NHS England where appropriate.

Not every difficult interaction justifies removal from the practice list. However, where behaviour becomes unreasonable, threatening, discriminatory or results in a breakdown of trust that prevents the provision of effective care, practices should consider the options available and act in accordance with NHS regulations and guidance.

Any questions in relation to this article, please dont hesitate to contact the LMC office.