General 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 listed at the end of this document, and the LMC recommends that your practice policies explicitly refer to one or more of these guidance documents or to this LMC guidance. The Parliamentary and Health Service Ombudsman has highlighted concerns about this issue on several occasions in recent years.
The relevant contractual terms are within Schedule 6, Part 2 of the GMS Regulations 2004. PMS contracts have the same provisions. Para. 20 (Removal from the list at the request of the Contractor), and Para. 21 (Removals from the list of patients who are violent) are the two relevant Paragraphs
Paragraph 20 deregistration
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.
General Practitioners need to keep a written record of:
- 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
Once a removal has been requested it should be sent to PCSE (acting on behalf of NHS England or the local Commissioners) and becomes effective eight days after notification, or earlier if the PCSE is advised the patient has already registered with another practice.
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.
Paragraph 21 deregistration
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 in writing/email confirming the decision. When the practice formally reports an incident to the local Police, they will be given an 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.
Incremental approach to recording and managing patient behaviours
Aside from the situation of unanticipated violence or abuse, the LMC recommends all practices adopt a step-by-step approach in considering whether a patient should be removed. It is professionally important to consider whether inadequate communication is in fact the problem, as studies have shown most patients who have been removed from practices say they did not understand why the decision had been taken.
Practices should therefore:
- Ensure all incidents that might lead to a warning or removal are identified.
- Discuss these incidents and inform appropriate clinicians and other practice staff; such as receptionists.
- Ensure all staff and doctors are aware of the relevant practice policy.
- Consider whether any aspect of practice organisation or clinical care could have contributed to the incident and could be remedied.
- Consider whether any aspect of practice organisation or clinical care could have contributed to the incident and could be remedied.
- Consider informing the patient, but when doing so, also suggesting ways in which the patient’s behaviour or actions may be altered and avoid inadvertently creating the difficulties that the practice is describing.
- Consider an informal discussion, or meeting, prior to a written warning, if the practice staff involved are willing to do so.
- Try to encourage the patient to understand the nature of the problem and also be prepared to listen to the patient’s perspective.
In this way both the practice and patient have an opportunity of resolving the apparent difficulties, which may have added benefits in terms of improving the doctor/patient relationship. If, however, it is impossible to achieve a successful outcome all involved will know they have tried to do so, and practice staff and doctors cannot subsequently be appropriately challenged or accused of making hasty or ill-considered decisions.
If a patient is removed, the removal letter should if sent, as well as explaining the decision, also include reassurance that the patient will not be left without NHS care, and that they can register with another practice. It should also include advice on where help can be obtained (normally from NHS England or the ICB) in terms of registration. A phone number should be obtained from the ICB to be included in the letter.
Other Family Members
An explanation (if relevant) that this decision does not apply to other members of the patient’s family may be helpful. Although there may be occasional circumstances when this is justified, particularly if a patient is being removed under Para 21 and they are a parent or carer who can be expected to be present when another relative needs to see a doctor, normally when a patient is removed other members of a family should not be simultaneously removed. They may be entirely unaware of their family member’s behaviour, or, in the case of children, not in a position to influence it. En bloc removal of patients who have not been warned of such a risk or who have not engaged in actions that may justify removal can create particularly adverse publicity (if, for example, the local MP or the Ombudsman is contacted) and a complaint which may prove difficult to justify.
Patients who live abroad for part of the year
This is a common scenario and can be a source of significant discontent. If a practice knows that a patient is residing abroad for a period of longer than three months, they can request deregistration on this ground. Practices are not required to do so, but PCSE is obliged to process this removal if it becomes aware of a patient’s absence outside the UK for over three months. Coupled to the issue is the patient reregistration with a practice on return to the UK; it may be, for example that such deregistered patients are not eligible to reregister with the practice from which they were deregistered, for example, if they live outside a patients practice boundary and the practice has a policy of not registering patients who live outside their boundary, but not removing patients who historically live there.
Clearly if patients are recurrently absence from the UK for periods of greater than three months on an annual basis, recurrent deregistration and registration are administratively time consuming but this would follow the Regulations.
Just because a patient is maintaining residency for tax purposes, or has UK citizenship, or has paid UK Tax or National Insurance in the past, does not entitle a patient to automatically maintain NHS registration with a UK General Practitioner. NHS primary care services are only available in the UK, although during the pandemic CNSGP Indemnity covered the delivery of remote services to patients stranded abroad because of travel restrictions.
General Practitioners should be particularly cautious about prescribing for patients who are abroad, and not prescribing for longer periods of time than are required for appropriate monitoring or follow-up in relation either to the medication that is being prescribed or the clinical condition that is being treated.
‘Inner ‘and ‘Outer’ Boundaries
Under Regulations introduced several years ago, practices are entitled [but are not required] to have an inner and outer boundary. If a practice maintains this, then patients who live within the ‘inner’ boundary and move (what is therefore usually a short distance) to live within the ‘outer’ boundary are entitled to remain registered with the practices.
Patients who move outside a practice’s outer boundary and who are currently registered with a practice, or who move outside the inner and outer boundaries, are not entitled to stay with a practice, although this depends on the practice’s policy. If practices are accepting patients’ registrations from outside their inner boundary, patients can register, this would include patients who live within or newly move to within the practice’s outer boundary.
Out-of-Area registrations
Also introduced some years ago, practices are entitled to maintain an ‘Out-of-Area’ registration for patients outside their inner boundary, whereby practices are not required to undertake Home Visits. OOHs service delivery is unaffected as the patient is treated as registered with the practice.
The LMC does not recommend practices maintain Out-of-Area registration status for patients because there is no uniform in-hours Home Visiting service available to provide this care to patients. This means that if, as they are entitled to do, patients contact the practice for clinical advice, and that advice is that a Home Visit is clinically appropriate, there is no service available for the practice clinician to request to provide this care. This creates a professional dilemma which transcends the contractual position.
In addition, GP practices cannot convert a currently registered patient to an ‘Out-of-Area’ registration: only patients who are not registered with the practice can be newly registered under the ‘Out-of-Area’ registration.
Patients registering after having been on the Special Allocation Scheme
A change in the Regulations in 2020/21 means that patients who have been transferred to the Special Allocation Scheme and are now deemed able to be appropriately reintegrated into General Practice by coming off the Scheme, cannot be reviewed or refused registration.
Practices are still able to deregister or refuse to register patients who are known to have been violent at other GP practices but who have not been placed and then removed from the Scheme; the point being that the Special Allocation Scheme is supposedly designed not just to provide a continuing primary care service but a rehabilitation service. However, the LMC recommends that practices ask the Scheme or ICB for written evidence that a risk assessment has been undertaken that documents the claim that will be made that a patient is can now be appropriately registered with “normal” General Practice. Simply coming to the end of a fixed period of time on the Scheme does not constitute such evidence, and without it Practices may state they remain at risk.
It is important in any communication with patients to remain entirely factual and polite.
Good Behaviour Guidance Agreement
Here you will see one example of what a Good Behaviour Guidance Agreement could look like, but do consider that such a document should be incorporated into your practice policy and applied non-discriminatory.