DEDUCTION OF PATIENTS FROM PRACTICE LIST POLICY

 

INTRODUCTION

There may be circumstances when it would be considered reasonable, or in the best interests of the patient, to remove patients from the list. The purpose of this policy, therefore, is to define the practice guidelines for removal of a patient from the practice list and to ensure that any concerns about removing patients from the list are dealt with fairly. The practice re-affirm its commitment to do everything possible to protect staff, patients and visitors from unacceptable behaviour and their zero tolerance approach to any incident that causes hurt, alarm damage or distress.

 

SITUATIONS WHICH JUSTIFY REMOVAL

 

• Moving Outside the Practice Registered Boundary
  1. In England
  2. Embarkation

 

• Unacceptable Behaviour or Violence
  1. Non-Violent / Abusive reasons for removal
  2. Violence / Crime and Deception – Lower level
  3. Violence / Crime and Deception – Serious

 

• Family / Household Members

 

SITUATIONS WHICH DO NOT JUSTIFY REMOVAL

 

• Patient complaints
• Patient choice on clinical matters
• Other reasons

 

MOVING OUTSIDE THE PRACTICE REGISTERED BOUNDARY

 

1. In England

Whitley House Surgery will not register anyone living outside the practice boundary.  A patient who moves outside the practice boundary will be deducted from the surgery list and is required to register at a new surgery whose boundary the house is within.

 

There are some patients registered who live in homes that are outside the current registered practice boundary. The most likely reason for this is that they were registered at the surgery prior to the introduction of practice boundaries. They will remain registered. If, however, new members join that household (or existing members move away and return to the household e.g. university students), they will be unable to register / re-register at Whitley House Surgery. The reason for this is because the house now lies outside the current practice area. In this instance the patient needs to register at a nearby GP Practice whose boundary the house is within.  

 

If a patient notifies the surgery that they have moved outside the registered boundary, the deduction process will begin. They will notified by the surgery that they will be deducted, and the local authority notified. Once notified they will have 30 days to register at a new surgery.

 

The same applies if we are notified due to e.g. returned mail, that a patient has moved outside the registered boundary.

 

1. Embarkation

Where a patient has moved abroad for a period of 3 months or more. On notification that the patient has moved abroad the patient will be removed from the Practice list within 3 months of that notification.

 

 

UNACCEPTABLE BEHAVIOUR OR VIOLENCE

 

1. Non-Violent / Abuse Reasons for Removal

In cases that do not involve violence or abuse, the decision to remove a patient should be taken after careful consideration. Patients who are abusing or misusing Practice services or staff should be given the opportunity to alter their behaviour if this is brought to their attention in the form of a warning letter.

 

A patient must have been issued a warning letter that they are at risk of removal (along with an explanation). It is good practice to have warnings in writing as this allows the opportunity to present and consider the reasons to be given for possible removal. The patient can discuss this with the surgery and share their perspective which can be taken into consideration. Medical Defence guidance will be sought where appropriate.

 

A record of the warning (including date, time and reason) must be kept by the Practice as the Local Area Team or NHS England may request a copy, and copies should be retained by the Practice after the patient has left the Practice List.

 

Irretrievable breakdown of the doctor - patient relationship.

Occasionally patients persistently act inconsiderately and their behaviour falls outside that which is normally considered to be reasonable. In such circumstances there may be a complete breakdown in the doctor-patient relationship.

 

 

 

Failure to attend pre-booked appointments

Repeated failure to attend pre-booked appointments is hugely wasteful to NHS resources and against the acceptable code of conduct for the surgery. Patients may be contacted regarding this and, failure to alter behaviour, may lead to removal from the practice list.

 

1. Violence / Crime and Deception – Lower Level

Each case will be discussed with all involved in the surgery and a partner. A majority agreement will be reached.  If it is to remove the patient it can be done under the 8-day rule. The Commissioning Group and Registration Department/PCSE will need to be contacted and a brief outline given. Following that agreement, the Practice Manager will write to the patient and explain the reasons for removal.

 

1. Violence / Crime and Deception - Serious

Any incident involving violence, crime or deception will be immediately reported to the Practice Manager who will complete an incident report and bring it to the attention of the practice partners. Staff involved should also make a written statement at the time as further evidence.  It may be so serious that the police may need to be contacted.

 

In such circumstances, the patient can be removed immediately by contacting the PCSE, advising them of the incident and giving them a log number that the police have given.

 

If a patient has displayed any violent, abusive or threatening behaviour towards the GP or any other member of Practice Staff that has required police intervention, that person can be removed without warning from the Practice patient list immediately.

 

When a patient:-

• Is physically violent or threatening towards a doctor, practice staff or other patients on the practice premises.
• Causes physical damage to practice premises or other patients’ property.
• Gives verbal abuse or makes threats towards the doctor, practice staff or other patients.
• Gives racist abuse, orally or physically.
• Sexual harassment of Practice staff or other patients.
• Stalking or inappropriate attachment to a GP or other member of staff.
• Is violent or uses or condones threatening behaviour to doctors (or some other members of the primary health care team) while visiting the patient’s home. Such behaviour may involve the patient, a relative, a household member, or pets (such as unchained dogs).*

*Removal can extend to any family living at the same address as any future visits may expose practice staff to harm if visiting the home, or if the perpetrator attends the Practice with a family member.

 

Crime & Deception

Where a patient:-

• Fraudulently obtains drugs for non-medical reasons.
• Deliberately lies to the doctor or other member of the primary health care team (e.g. by giving a false name or false medical history) in order to obtain a service or benefit by deception.
• Attempts to use the doctor to conceal or aid any criminal activity.
• Steals from practice premises.

 

 

 

FAMILY / HOUSEHOLD MEMBERS

 

When a decision is made to remove a patient from the practice list, the removal may well be extended to other members of the family or household.

 

If the behavior of one member of a household or family has led to their removal, this does not mean that the removal of other family members should automatically follow. An explicit discussion, whilst protecting the confidentially of the removed patient, with other family members about the problem and the doctor's concerns will often obviate the need for any further action.

In rare cases however, because of the possible need to visit patients at home, it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behavior resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family.

 

This is particularly likely where the patient has been removed because of violence or threatening behavior and keeping the other family members could put doctors or their staff at risk.

The practice should always consider how it would look to outside observers if a family were to be summarily removed from the list, in haste, without explanation, for a single misdemeanor or disagreement with one family member.

 

 

SITUATIONS THAT DO NOT JUSTIFY REMOVAL

Complaints

A patient cannot be removed from a Practice list if they have made a complaint (formal or informal), nor for occasionally or persistently questioning clinical techniques, safety measures or other practice matters.

 

However it may be agreed if the basis of the complaint results in the relationship between the GP and the patient breaking down and cannot be resolved (either because of complaints or legal action), that the patient may be advised to change their Practice.

 

Patient Choice on Clinical Matters

• Choosing a valid course of treatment that may be problematic for the practice (e.g. home treatment or confinement)
• Refusing to take part in local or national screening programmes (e.g. cervical screening)
• Refusing to take part (or allow dependants to take part) in local/national preventive medicine programmes (e.g. child immunisations)
• Does not comply with health advice given by GP.

 

Other Reasons

• Patient has highly dependent condition or disability.
• Treatment is considered to be too expensive.
• If patient has high degree of concern or anxiety about their condition.
• Discrimination of any nature against the patient and/or their relatives.