Managing Patient Behaviour and Patient Removal

This resource provides guidance for general practices on managing challenging patient behaviour and, where appropriate, removing a registered patient from the practice list at the request of the partnership [contractor], in line with Schedule 6, Part 2 of the General Medical Services Regulations 2024.

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Introduction 

Deciding to remove a patient from a practice list is normally the action of last resort for most General Practitioners. It can be an upsetting experience for all involved, and may have significant implications, both for the patient and the practice. It is important for all practices to have a policy in place for this process, and for all practice staff and doctors to be aware of and follow the practice guidance carefully. Although there is no formal ‘Appeal’ process against such deregistration, such a decision may generate a complaint and cause widespread adverse publicity. 

Practices should also note that as part of a CQC Inspection or Healthwatch visit, they must demonstrate they have a policy in place and that General Practitioners and Practice Managers are using this policy when making such decisions. 

The amount of professional advice available reflects the importance of this issue. Examples are singposted within resource, and the LMC recommends that your practice policies explicitly refer to one or more of these guidance documents and/or to this resource page. The Parliamentary and Health Service Ombudsman has highlighted concerns about this issue on several occasions in recent years. 

The Regulations

The relevant contractual terms are within Schedule 6, Part 2 of the GMS Regulations 2004; the relevant paragraphs can be found here:

  • Para. 20: Removal from the list at the request of the Contractor, and
  • Para. 21: Removals from the list of patients who are violent
  • Para. 23: Removals from the list of patients who have moved

PMS contracts have the same provisions.

Para. 20: Removal from the list at the request of the Contractor

Under these arrangements General Practitioners should:

  • Not remove a patient for discriminatory reasons; in addition, the LMC recommends it should be an exceptional decision to remove patients (even if this is justified under Para. 20) if the practice has received a complaint from that patient or until the process of resolving it is complete. 
  • Provide a reason for the decision to remove: however, if a more specific reason cannot be used it is acceptable for the reason given to state that there has been an irrevocable breakdown in the relationship between the patient and the doctor. 
  • Give the patient a warning that they are at risk of removal, and why. Normally a patient should not be removed unless they have received such a warning over the previous twelve months. While there is no requirement for this warning to be in writing, document the circumstances of the warning for subsequent reference if a letter is not sent. 

    Exceptions to giving this warning are if the GP has reasonable grounds for believing such a warning would:

    • Cause harm to the patient’s physical or mental health
    • Put at risk a member of the practice team

Once a removal has been requested, the notification should be sent to PCSE, acting on behalf of NHS England or the local commissioners. The removal takes effect 8 days after notification, or earlier if PCSE is informed that the patient has already registered with another practice.

Any warning given to patients, and the reason(s) a warning was given. 

  • Why a warning would have been given directly to the patient, but was not (as this provides a record which may be used if a patient is subsequently removed).
  • When a patient is removed, and the reason(s) given for this, noting that “irrevocable breakdown” can be a default reason if no other reason is used.

NHS England or local Commissioners are entitled to inspect these records on request

Para. 21: Removals from the list of patients who are violent

Para. 21 refers to patients who are violent or whose behaviour means others (essentially practice staff or other patients) fear for their safety. In such cases, providing the practice reports the incident to the police, a patient can be removed with immediate effect. A police number can be obtained, even if the police do not attend an incident. PCSE may initially be informed of this decision by phone but should subsequently be contacted formally confirming the decision. When the practice formally reports an incident to the local Police, they will be given a Police Incident Number, which should be retained within the record of the deregistration process. 

Patients should also be informed of this decision, though not if this is impractical to do, or if doing so may cause harm to the patient’s physical or mental health or place at risk a member of the practice staff or a doctor. 

GPs should also note in a patient’s medical records if they have been removed from the practice list under this paragraph and the reason(s) why this decision was taken, but only in factual terms, no opinions should be entered. 

Once a removal has been requested it should be sent to PCSE (acting on behalf of NHS England or the local Commissioners) and once approved becomes effective immediately. A request for immediate removal is a request for patient care to be provided under the SAS Scheme. 

Para. 23: Removals from the list of patients who have moved

If a patient is being removed because they have moved outside the practice area (distinguishing this from patients who are already living outside a practice boundary) then the practice is responsible for that patients care for up to 30 days, but there is no requirement to make a home visit during this time. This in effect converts a patient to “out-of-area” registration status. Patients should be informed that during this period, until their deregistration takes effect, that is, 30 days after PCSE notification, they do not have access to an in-hours Home Visiting Service, unless one is available locally, commissioned by the ICB, which is not the case locally, although practices are not required to withdraw a Home Visiting Service in these circumstances. If patients re-register at another practice, then all essential services would then be delivered by that new practice, and this would be from the date of that new registration, which may be within the 30-day period. 

If a patient has moved outside of the practice boundary area, do not action the change of address on your clinical system, but instead request a deduction with PCSE; a guidance note for this process can be seen here. Once the deduction is received, PCSE will place the patient on a pending deduction for 30 days.