MDU advises GPs to seek resolution not removal

18 October 2011

GPs should think carefully about whether disputes with patients can be resolved rather than removing patients from their lists says the MDU. In the light of today's Health Service Ombudsman report into complaints handling, which showed that 21% of patient complaints about GPs investigated by the Ombudsman concerned removals from a practice list, the MDU issued fresh advice to GP members who are considering this step.

MDU Head of advisory services, Dr Michael Devlin, said: “To put this report in context, the 48 complaints against GPs which were investigated and reported on by the Health Service Ombudsman represents a tiny proportion of the 300million GP consultations estimated to place in England each year. However, it's important we are all alive to any emerging trends and it is clear from the report that the Ombudsman's office is investigating more complaints about removals from practice lists which it believes are happening without fair warning or proper explanation.

“The removal of a patient was also one of the top ten reasons for complaints notified by GPs to the MDU in 2009-2010 and we regularly receive calls to our advice line on this topic. This is often the culmination of a series of misunderstandings and difficulties which has left the doctor believing they have little option, for example, patients who are regularly abusive towards practice staff. While it may be understandable that a doctor feels at the end of their tether, removing a patient is rarely straightforward decision and should only be considered in exceptional circumstances after other options to resolve the problem have been explored.”

The MDU today issued the following advice to doctors considering removing a patient from a list:

If a patient's behaviour is a cause for concern, talk to them and explain why and try to determine what may lie behind it. Consider alternative ways resolving any long-running disagreements, such as mediation.

If such discussions are unproductive, the patient can generally be warned if they do not change their behaviour, they risk removal from the practice list. Unless there are certain circumstances, such as violence, you are contractually obliged to have given the patient a warning in the 12 months preceding removal from your list.

Before you end a professional relationship with a patient, you must always be satisfied that your decision is fair and not influenced by any personal grievance. For example, while it may be awkward to treat a patient who has made a complaint about you or your practice, the GMC says that this does not justify their removal. Seek advice from your medical defence organisation before acting if you are in any doubt.

Even if there is good cause to remove a patient, this rarely justifies removing their family as well.
On the rare occasions where the doctor-patient relationship has irretrievably broken down, and removal is necessary, you should act in line with your contractual and ethical obligations. This means you should inform the patient and the primary care organisation (PCO) in writing of your decision and the reasons.

The patient should be given clear information about how to register with another practice. The GMC says you must take steps to ensure that arrangements are made promptly for the continuing care of the patient, and you must pass on the patient's records without delay

Keep a clear and detailed note of any incidents that have led to the removal (including statements from relevant staff members); any steps that have been taken to resolve the situation; the specific reasons for the removal and the process of removal that was followed (for example discussion at a practice meeting where minutes were kept).

Any decision to remove a patient from your list should be taken by those who are not directly involved in the disagreements giving rise to the removal.

If you decide to remove a violent patient from the practice list, you should report the incident to the police first and obtain an incident number before informing the PCO in writing, either immediately or within seven days in order to comply with contractual commitments. When a patient has been violent and you fear further violence, it may be inappropriate to provide a detailed explanation to the patient when removing them from the list. In this case, it will be the responsibility of the PCO to arrange primary care services, if necessary, within a more secure setting.

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