Volume 20.4 
Oct 2004

Removal of patients under the New Contract

The New Contract has now been in place since April. It's still early days for doctors who have signed the New Contract, writes Nick Clements, and fair to say a number of aspects of how the contract will apply in practice remain unclear

One area of the new GMS contract which represents a significant change to the previous arrangements are the circumstances where doctors may remove patients from their list. Under the old Terms of Service a doctor could ask the PCT to remove a patient from his list for any reason, or no reason at all. There was no requirement for the doctor to notify the patient, or to give any explanation.

Over the years this right was increasingly questioned by patients and their representatives. Latterly, the Health Service Commissioner (Ombudsman) has been critical of doctors exercising the right to remove patients from their list where he has considered that removal to be unjustified or unreasonable. He has been critical where patients have been removed without warning or notification, and without reasons being given, even though there were no Terms of Service duty to do this.

Advice from various bodies, including the RCGP and the GMC, has served to underline these issues, the general thrust being that the right to remove should be exercised reasonably. The GMC for example, gives advice in the booklet 'Good Medical Practice', published in 2001 about ending professional relationships with patients at paragraphs 24 and 25.

Amongst other things, this advised that the decision (to terminate the relationship) should be fair, should not be made solely because the patient had complained, or because of the financial impact of their care or treatment on the doctor's practice. The GMC also advised that in such circumstances the doctor should inform the patient (orally or in writing) why they had decided to terminate the relationship.

Over the years, the right to have patients removed from the list was effectively amended by published advice and guidelines, whilst technically remaining unchanged in the Terms of Service. The new contract alters the position with new provisions relating to removals, which are now much more in line with the previous advice.

'Reasonable' removals

Firstly, the contract specifies that all removals initiated by the practice must be 'reasonable'. Reasonableness is not defined in the contract, but specific reasons for removals are listed, which are effectively held never to be reasonable. These are any reasons related to age, sex, sexual orientation, appearance, medical condition or disability. As an aside, practices with open lists may only refuse to accept applications to join the list for almost identical reasons.

There is now also an obligation to notify the patient of their removal and to provide written details of the reasons for the removal. However, in recognition of the potential difficulties facing practices, there are special provisions which can be used in certain circumstances. Specifically, the practice or doctor can fall back on 'irrevocable breakdown in the relationship' as the reason given for removal, where, in the reasonable opinion of the contractor, the relationship has broken down and it is considered inappropriate to give a more specific reason.

However, a removal can only be requested if the patient has been issued with a written warning within the 12 months prior to the removal. The warning must inform the patient that he is at risk of removal, and the reasons for this explained. The contract does not specify a minimum period between the warning and the removal. But common sense would dictate that a reasonable amount of time should elapse so as to give the opportunity to modify their behaviour.

There are certain specified circumstances where a warning need not be issued. Firstly, where the reason for removal relates to a change of address. Secondly, where the contractor has reasonable grounds for believing that the issuing of such a warning would be harmful to the physical or mental health of the patient.

The warning can also be withheld if the contractor has reasonable grounds for believing that issuing it could put at risk the safety of one or more of the following: the contractor, his partners, a member of staff or anyone present on the practice premises, or wherever services are being provided to the patient under the contract.

If the contractor is a company, the list includes any legal and beneficial owner of shares in the company. Finally, the warning can be withheld if the contractor believes it would not be reasonable or practicable to issue the warning. There are special provisions where the contractor asks for a patient to be removed immediately in cases involving violence - see below.

The contractor must make a written record of the date of any warning given, and the reasons for such a warning, as explained to the patient. If no warning was given, a record must be kept of the reason for not issuing a warning.

The contractor is also obliged to keep written records of removals. The record must include the reason for removal that has been given to the patient and the circumstances of the removal. Where the contractor has given the reason as 'irrevocable breakdown in the relationship', as described above, he must record the grounds for a more specific reason not being appropriate. The records must be made available to the PCT on request.

For normal removals (those not taking place with immediate effect - see below), the removal takes effect on the eighth day after the PCT receives notice, or from the date on which the patient registers elsewhere, if that is sooner. However, if on the date on which the removal would take place, the contractor is treating the patient at intervals of less than seven days, the contractor must inform the PCT in writing. Thereafter, the removal will not take place until eight days after the PCT is notified by the contractor that the person no longer needs such treatment, or on the date they register elsewhere - whichever is the sooner.

Immediate removal

In cases of violence, or threatened violence, there are special provisions in place to allow immediate removal from the list. Such removals can be made where the patient has committed an act of violence against a specified person, or has behaved in such a way so that any of the specified persons has feared for their safety.

The specified persons are the contractor, his partners, a member of staff, any persons engaged by the contractor to perform or assist in the performance of services under the contract (this would include locums) or anyone present on the practice premises, or wherever the services were provided to the patient under the contract. Where the contract is with a company, the list includes any legal and beneficial owner of shares in the company. The incident in question must have been reported to the police in order for a request for immediate removal to be made.

Where an immediate removal has been requested, the contractor should still inform the patient, unless it is not reasonably practicable to do so, or there are reasonable grounds for believing that doing so would be harmful to the physical or mental health of the patient, or put one of the specified persons (see above) at risk.

Where a patient is removed from the list because of violence, or the threat of it, the contractor is obliged to record in the patient's medical records that the patient has been removed under those provisions, and to record the circumstances leading to the removal. The reason for this seems to be to provide appropriate notice to subsequent practices, so that staff can be properly forewarned and protected. It need hardly be said that such a record must be made carefully - it should be both objective and accurate.

PCTs have a responsibility to ensure there is a service available for patients who are difficult to manage.

The position for PMS practices is less clear, as contracts vary. However, one of the underlying stated principles for PMS is that no patient of a PMS practice shall be disadvantaged in comparison with a GMS practice. From a practical point of view it would therefore be sensible for PMS practices to mirror the GMS process.

So there we have it: quite a substantial change to the old terms of service. I am sure that some will be sorry to see the disappearance of the old blanket right to remove, even if they seldom or never used it. Certainly the changes do impose further regulations and administration on practices, and this is unwelcome. But on the positive side, the requirements of the contract now effectively mirror the advice given by other bodies on this issue. The disappearance of this discrepancy should hopefully leave doctors with a clearer idea of when and how they are expected to exercise the right to removal, which will in turn hopefully lead to fewer problems and complaints in this area.