Dealing with difficult patients; Removal of Patients from GP Lists

Kent LMC Advice

Please read the GPC Guidance before deciding how to proceed to remove a patient. The LMC advice builds on the GPC guidance with some suggested standard processes and letters that you can adopt. Also attached is a suggested Practice Charter that should be part of your practice leaflet and on your practice website. Below are suggested processes for advising patients about their behaviour or the way that they use services. The process should not be used to remove patients for trivial reasons even where these are repeated. Practices should seek to use all available services to change patient behaviour.

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1.  Verbal Warning

• Useful for low level difficult behaviour/first warning.
• Format - arrange a meeting with the PM/GP to explain standards expected of patients.
• Refer to the Practice Leaflet and Practice Charter (Appendix E).
• Use the meeting to change behaviour. Keep a File note and explain to the patient that it will be kept for one year.      

2.  Letter of Concern/Warning letter               

• useful where there is a repeat of behaviour where a verbal warning has failed or where there have been repeated DNA’s
• Draft letter of concern (Appendix A)
• Template Warning letter
• Template Good Behaviour Guidance Agreement

3.  First Stage Yellow Card

• It is a requirement of the regulations that before removing a patient a letter be sent warning that the unacceptable behaviour may lead to removal if it is repeated within 1 year
• Yellow card letter can be used when a letter of concern has not had the desired effect or if a serious incident has occurred
• See Appendix B for a draft letter
• If the patient decides to appeal against the decision to send a yellow card then arrange a meeting with the patient. It helps to encourage the patient to seek support from Kent Advocacy –  https://www.theadvocacypeople.org.uk/

4.  Second Stage Red Card Removal

• If the patients behaviour does not improve or there is a repetition of the type of incidents that caused the yellow card letter then removal may be appropriate
• Removal still requires that the patient doctor relationship has to have broken down irretrievably.
• Be aware that removal will often trigger a complaint which can end up being considered by the Ombudsman who will scrutinise both the process and the reason for removal so be clear that removal decision is defensible.
• See Appendix C for a draft letter
• Notify Primary Care Support England (PCSE) of the removal

5.  Immediate removal – Violent/Abusive Behaviour

• Immediate does mean Immediate. Action is required the same day unless there are good reasons why it cannot be actioned immediately
• If possible take advice from the LMC Office or your HaCP
• Notify the police. This is a requirement. You do not need a crime number. A simple letter outlining the incident and naming the patient is sufficient. If the incident is very serious resulting in physical harm to staff or patients seek urgent support from the police, dial 999 if necessary particularly if the patient needs to be removed from the premises
• Formal letter to the patient Appendix D
• Notify PCSE using their form available HERE
• Keep copies of all letters