Be sure your decision is fair and justifiable.
Meet your contractual obligations.
Only remove the patient, not their family.
Follow the GMC's guidance on ending your professional relationship with a patient.

Ending a professional relationship vs deregistration from a GP practice list

The ending of a professional relationship between one or more healthcare professionals and a patient does not always mean the patient will need to be removed from the practice list.

If you are considering ending your relationship, follow the GMC's guidance. You should only end your professional relationship with a patient when there has been an irrevocable breakdown of trust. You must be satisfied your reason is fair and does not discriminate against the patient.

The trust between you and your patient might have broken down to the extent that you cannot continue to provide them with good care, for example because they have threatened you or made a sexual advance. You should not end a professional relationship with a patient solely because they have complained.

It is reasonable to end your relationship without warning in some circumstances, such as if the patient has been violent. But you should usually warn the patient and do what you can to restore the relationship, before you decide to end it.

If you do still need to end your relationship with a patient, discuss with colleagues. There may be ways to continue to care for the patient at the practice, for example if a colleague can take over their care.

Keep careful records and make sure the patient is informed.

In some circumstances it may be impractical to continue to care for the patient at the practice - if one doctor has ended their relationship with the patient and would sometimes be the only available doctor, or if the unacceptable behaviour has been against the practice as a whole - so you may need to consider removal from the practice list.

The need to be fair

Removing a patient is usually the last resort for doctors following a series of incidents, but it's not always the end of the story. Aggrieved ex-patients can make a complaint, contact the press or post their feelings on social media.

Removing a patient could also lead to criticism by the GMC and the ombudsman. It's therefore important that you're able to justify your decision.

Justifiable grounds for removing a patient might include:

violence or threatening behaviour
discriminatory abuse
sexual advances
theft from the practice, staff or other patients
persistent unreasonable behaviour.

It would be difficult to justify removing a patient based on the following:

they have complained
their disruptive behaviour is caused by their condition
they are close to another patient who is being removed
you are concerned about the resource implications of their care or treatment
their medical condition puts you at risk.

Contact us for individual advice if you're unsure.

Removing a patient from the list

Follow these steps to meet your ethical and contractual obligations.

Do what you can to restore the professional relationship. For example, find out what might be behind their actions and whether this could be addressed with extra support. You could also consider an acceptable behaviour agreement.
Warn the patient explicitly what aspects of their behaviour are unacceptable and that you will end your professional relationship if they don't change. The patient needs to know exactly what they need to stop doing and what will happen if they don't. GPs are usually contractually obliged to have issued a warning during the 12 months before removal. Keep a record of your discussion and follow up your warning in writing.
Tell the patient of your decision and explain the reasons, in writing if possible, and be clear they will not be left without medical care.
Make a record of your decision, which should be factual and objective. The GMC says you "should not include anything that could unfairly prejudice the patient's future treatment."
Consult and follow relevant local guidance and regulations.
Make sure arrangements are in place for the continuing care of the patient if they are unable to make arrangements for themselves
You must seek advice from a safeguarding lead if you are concerned that ending a relationship with a patient could leave them, or someone close to them, at risk of significant harm.
Notify your local Primary Care Organisation (PCO) in writing of your decision and the reasons, in line with your NHS contract.
The PCO will notify you and the patient in writing. The removal will usually take effect when the patient is registered with another provider or the eighth day after the notice has been received, whichever is sooner.
Transfer the patient's records to their new practice as soon as possible.

Violent patients

In its guidance, the GMC says: "It may be reasonable to end a relationship immediately in certain circumstances. For example, primary care regulations and contracts allow for the immediate removal of patients from practice lists if a patient has been violent or behaved a way that has caused other people to fear for their safety. You must follow local or national guidance and regulations."

In this situation, you should follow the steps below:

Report the incident to the police and get an incident number. Only give the minimum information needed to allow for proper investigation. The patient's medical details will not usually be required.
Notify the PCO and confirm in writing, either immediately or within seven days. The removal will take effect when the notification has been received.
Tell the patient, unless it would be unsafe or impracticable to have further contact. Speak to your PCO if this is the case.
The PCO will notify the patient in writing and arrange for their ongoing care, in a secure setting if necessary.
Keep relevant witness statements and records of the decision for removal in a file separate from the clinical records.
Ensure that the patient's clinical records are provided to their new doctor without delay.

For more on this, read our MDU journal article on dealing with threats and violence.

Get advice early

Members are always welcome to contact us for specific advice and support before deciding whether to warn a patient or end a professional relationship with a patient.

Here are some other MDU resources that might help:

Introduction to conflict resolution (webinar)
Warning letters to patients: a practical guide (MDU journal)
Warning letters and removing patients from the practice list (e-learning course)

Fictional scenario

A male patient in his 50s, suffering known depression and anger management issues, had complained several times to the practice about his care and was known to be 'difficult'.

One morning, he came to reception asking for an urgent appointment (for a non-urgent issue). A doctor happened to be in the reception area and the exchange culminated in the patient jabbing his finger towards the doctor, shouting expletives and threatening to 'see you in court' before slamming the door on the way out.

The GP spoke with colleagues, who expressed a preference for the patient to be removed from the list.

Our advice

The MDU advised that even though the patient's behaviour was unpleasant, it did not reach the threshold of a threat to safety, which would more typically justify an immediate deregistration. The patient might argue that his threat to 'see you in court' was an expression of complaint, made in the context of his known problems.

As a result, the GP decided to ask the patient to meet at the practice. The GP and practice manager used the meeting to listen to the patient's concerns, manage his expectations of care and explain what aspects of his behaviour had caused upset.

The outcome

The patient agreed to modify his behaviour and to a behaviour contract. But the following month, the patient repeated his behaviour with more swearing and shouting in the reception area. This time, with the MDU's support, the practice sent him a letter of warning.

Removing patients from a GP practice list

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