GPs are subjected to violence, rudeness and anti-social behaviour almost every week.Yet few practices have a policy on removing patients. Sally Young and Relton Cummings report

The removal of patients from GPs' lists taxes doctors and patients alike.Although the number of patient removals is recorded, the reasons are not - unless patients are violent and are a potential threat to staff.For some patients the first they know of their removal is a letter from the health authority.GPs may often see particular patterns of behaviour recurring in the 'difficult' patient, but removal may not bring about change in the patients'behaviour.Community health councils have to deal with patients who are upset and unclear why they have been removed.The media, left to speculate in this vacuum, have often suggested treatment costs may be the motivation for removal.

There has been relatively little research in this area.The best known is a study by the former Kent family health services authority in 1995, Royal College of General Practitioners guidance in 1997 and a booklet produced by Nott ingham loca l medica l committee and Nottingham HA in 1998.

In Newcastle and North Tyneside, the number of patients removed from lists is no higher than elsewhere and, indeed, is apparently low for inner-city areas.

Nevertheless, the LMC, local HA and the two local CHCs recognised that this issue needed to be addressed.

A postal survey was conducted to discover the extent of the problem and key themes for general practice in Newcastle and North Tyneside.A questionnaire was drawn up with input from the chief officers of the CHCs and HA.

It was then approved by the LMC before distribution.

The questionnaire and covering letter were sent to each of the 277 GPs in Newcastle and North Tyneside.There were 159 responses (57 per cent) - high for GP postal questionnaires.Analysis showed a variation in response rate dependent on practice size.Only two of nine singlehanded practices, and five doctors from two-handed practices (out of 10 practices) had responded.There was a response from all but one of the other 59 practices, which had three or more practitioners.Although the survey cannot be regarded as a representative sample, it provides a useful snapshot of doctors'views and attitudes.

Most respondents (77 per cent) removed fewer than three patients from their lists in an average year.The average list size for each GP is 1,800.However,62 per cent of respondents had considered removing three or more patients.This appears to demonstrate restraint and reflection on the GP's part.

The CHC representatives had expressed concerns that patients could be forced into removing themselves from lists.But questions about GPs advising patients to reregister because of a breakdown in the doctor-patient relationship illustrated that only 7 per cent of respondents did this with three or more patients a year.Only 32 per cent of practices had a policy on the removal of patients.

When asked if other family members were removed at the same time as an individual patient,38 per cent of respondents said this did happen.When asked why, the most common reason cited was violence or threat of violence, and potential safety concerns during home visits to the same household.The CHC officers had previously noted complaints about this issue.

Most (64 per cent) respondents informed patients in advance of removal, with 58 per cent giving a reason as a matter of course, and a further 26 per cent willing to give a reason if asked.Four per cent of respondents said they would not give a reason for removal and the most common explanation cited was fear of violence and reprisal.Most (76 per cent) respondents were aware of the British Medical Association and General Medical Council guidelines on giving reasons when removing patients.

Respondents were given further specific situations and asked if they considered them sufficient grounds to remove a patient immediately from their list immediately - or if the problem persisted.There were few surprises - offensive language, violence (threatened or actual) and racial abuse being most likely to result in immediate removal.Very few (3 per cent) viewed complaints against GPs or staff as a reason for immediate removal.But persistent complaints and questioning of practice standards resulted in a higher number of removals.

Breakdown in communications (69 per cent) and inappropriate use of services (75 per cent) were far and away the highest-ranking reasons for potential removal, with offensive language (67 per cent) and non-attendance (43 per cent) the next main reasons. Interestingly, given the importance attached to GP targets, refusing smears (1 per cent) and immunisation (2 per cent) were very low. If a woman requested a home birth,1 per cent of respondents would remove the patient immediately and 2 per cent if a persistent request was made.

When GPs were asked the main reason for removal of patients,79 per cent of respondents cited violence, rudeness and antisocial behaviour.Breakdown of relationship and abuse of services were also ranked quite highly.When asked to expand, abuse of home visit requests, 'out of hours'calls and 'emergencies'were cited.

Although there was no specific question about the cost of expensive treatments as a reason for removal, none of the respondents cited cost as an issue in the 'other'category.

Patients who do not attend are a source of concern within the NHS.GPs have different appointment systems - some with sessions, other with fixed appointments.Fortyone per cent of respondents lost at least one hour a week to patients who did not attend and 20 per cent lost at least one-and-a-half hours a week.Almost half (45 per cent) of the practices had an agreed policy on non-attenders.

It was of great concern that 19 per cent of practice receptionists reported having to deal with at least three episodes of verbal abuse and threats per week, with a further 13 per cent dealing with more than five incidents per week.Not all practices appeared to have policies on this issue.

When asked to define which aspects of patient behaviour GPs found most problematic, regular requests for late calls, 'emergencies', drug abuse and prescription fraud were cited as being a frequent problem for some practices.

Most respondents (81 per cent) felt that the practice leaflet offered clear explanations of how the service should be accessed; 13 per cent disagreed.

Only 18 per cent of respondents had used a lay conciliator to help them to resolve difficult problems with patients and, of these, half found it helpful and half found no benefit.

The survey demonstrated that GPs do consider the effects of patient removals.There will always be a small number of removals done in the heat of the moment and for which some reflection might find other solutions.

Alternative ways of dealing with these issues might come from a good practice guide.Respondents supplied copies of internal protocols and procedures.

Suggestions for action Practices should check whether their information leaflets to patients offer clear advice and information on where and when to access the practice for services, and also about NHS Direct and the use of hospital accident and emergency services.

Practices should provide patients with clear information on the policy for house-calls.

Practices should draw up policies for dealing with nonattenders.

Practices should establish policies for removal of patients - using examples and standard leaflets.

Where appropriate, reasons for refusal should be given, with standard phrasing used. The use of standard letters should also be considered.

Consideration should be given to using a third party, such as an HA lay conciliator, with patients who persistently fail to follow advice on the use of services.

There needs to be a clear health and safety policy for staff. This should include pract ice v isits, training for staff, and the provision of appropriate equipment such as panic alarms.Practices should also dopt a policy of zero tolerance to violence against staff, as detailed in recent Department of Health circulars.

A practice incident book would help to document events and highlight persistent problems with systems and individuals.

A mechanism for alerting the HA about problem patients is needed.

The use of a combined HA/local medical committee facilitator for repeatedly violent and abusive patients should be considered.

Key points

A survey of GPs in Newcastle and North Tyneside found most respondents removed fewer than three patients a year from their lists.

Most practices did not have a policy on removals.

More than three-quarters of removals were for v iolence, rudeness or anti-social behaviour.

The survey suggests that practices should keep a record of violent incidents and that a facilitator should be made available to help practices with patients who are repeatedly violent.

Main reasons for removing patients No Percentage

Violence 78 49

Rudeness/behaviour 35 22

Relationship breakdown 29 18

Abuse of services 29 18

Non-attendance 9 6

Drugs 7 4

Out of area 8 5

Prescription fraud 5 3

Criticism 3 2

REFERENCES

1 Perry J.Removed from Care: a report of patients removed from GP lists at the doctor's request. Kent FHSA, July 1995.

2 Removal of Patients from GP Lists: guidance for college members.Royal College of General Practitioners, London. 1997.

3 Difficult Patients : guidance for GPs and their staff, Nottingham LMC and Nottingham health authority, 1998.

4 Press releases 1999/615 and 1999/0775.Department of Health, 1999.

Dr Relton Cummings is a GP in Newcastle upon Tyne and vice-chair of Newcastle and North Tyneside local medical committee; Sally Young is chief officer, North Tyneside community health council.