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.
Practice 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 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.