Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
Why are patients removed from their doctors' lists? A comparison of patients' and doctors' accounts of removal
Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield S1 4DA, UK
E-mail: F.C.Sampson{at}sheffield.ac.uk
Received 6 June 2003; Revised 7 January 2004; Accepted 17 May 2004.
Sampson F, Munro J, Pickin M and Nicholl J. Why are patients removed from their doctors' lists? A comparison of patients' and doctors' accounts of removal. Family Practice 2004; 21: 515–518.
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Abstract |
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Background. GPs in the UK may remove a patient from their list without supplying a reason to the patient or the local health authority. Little is known of the events that lead to such removal decisions, nor of patients' views of their removal.
Objective. Our aim was to describe the events that lead to a removal from both the doctor and patient perspectives.
Methods. An anonymized postal survey of 204 GPs and 319 patients with recent experience of removal was carried out.
Results. Violent, threatening or abusive behaviour was the most common reason for removal given by GPs (64%, 57 out of 89), with almost half of instances involving verbal abuse towards receptionists (42 out of 89). However, fewer than a fifth of patients admitted to threatening or abusive behaviour towards practice staff (15 out of 76). Although GPs reported giving patients a reason for the removal in 59% (44 out of 75) of cases, only 36% (26 out of 72) of patients reported receiving a reason. Patients often appeared not to understand why they had been removed.
Conclusions. While doctors and patients frequently give differing accounts of the events which lead to removal, both emphasize relationship breakdown and loss of trust. Financial issues appear negligible. Since few removals seem preventable by policy measures, the distress of removal might best be reduced by trying to improve the removal process—probably through improved communication—rather than prevent removals.
Keywords. De-registration, doctor–patient relationship, GP lists, removals.
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Introduction |
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The NHS allows UK GPs to remove a patient from their list without supplying a reason to either the patient or the local health authority.1 Media reporting of this issue has speculated that patients are removed because they are expensive or refuse interventions for which targets have been set. Two previous surveys have reported reasons for patient removal from the GP perspective.2,3 Little research has examined removal from the patients perspective.4,5 We undertook postal surveys of recently removed patients and their GPs to describe the events prompting the removal decision, from both doctor and patient perspectives.6
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Methods |
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We obtained anonymized data from six former health authorities in England on patient removals between July and October 2000. Where multiple patients were removed as a group, we selected a single patient from the group. We included the GPs of all sampled patients. GPs were asked why the patient was removed, using a list of potential reasons obtained from a national survey,3 and details of violent, threatening or abusive behaviour were sought using categories from a survey of aggression in general practice.7 Patients were asked for an account of the events preceding removal. Since a person may not know why they were removed, we asked patients to consider a list of statements and indicate which might apply to them. These were intended as a non-judgemental counterpart to the list of reasons given to GPs. Both GPs and patients were asked about communication before and after the removal.
To meet confidentiality requirements, both surveys were mailed by local health authorities, with up to two reminders. Responses, identified only by study number, were returned directly to us. We remained unaware of the identity of all respondents, and this was made clear in a covering letter. We restricted analysis to removals where the patient had not moved out of the practice area.
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Results |
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The GP survey achieved a 77% response rate (158 out of 204), and the patient survey a 38% response rate (120 out of 319). The patient survey showed some response bias: the mean age of responders was 39 years, and of non-responders 31 years (t = 4.381, df = 223, P < 0.001).
Excluding cases where removal followed the patient moving away, 89 GP responses and 77 patient responses were available for analysis. Among these, the mean age of GPs was 46 years; 74% (64 out of 87) were male; and median practice list size was 6500. The mean age of patients was 37 years (n = 56); 53% were male (40 out of 76). GPs reported that 44% of the removed patients were drug or substance misusers, 12% had a chronic medical condition and 17% had a mental illness.
Doctors' accounts of the removal
Violent, threatening or abusive behaviour was the most common reason for removal given by GPs (Table 1). Among these cases, verbal abuse was the most common type (91%, 52 out of 57), followed by specific verbal threats or physical action against property (42%, 24 out of 57). Reception staff were most often the target of verbal abuse, in 81% (42/52) of such incidents, while GPs were involved in 52% (27/52). In nine cases, other patients were the target of abuse.
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Patients' accounts of the removal
In terms of possible factors corresponding to those presented to GPs, patients most commonly noted a "need to visit a doctor often" (30 out of 76, 39.5%) and a "need for a GP home visit" (14.5%, 11 out of 76). Over one-third of patients said they had told the doctor they disagreed with their treatment or advice. One patient had refused a cervical smear; none reported refusing immunization. A fifth of patients (15 out of 76, 19.7%) admitted threatening, shouting at, attacking or pushing the doctor, their staff or patients.
Patient accounts of the removal were often unclear, and we were able to understand what had happened in only 39 of the 77 accounts. A further 21 patients offered an explanation, or described a situation which they linked to the removal, but the reason remained uncertain. The remaining 17 patients said they did not know the reason.
Thirteen patients described an abusive incident involving the doctor or practice staff. However, while GPs described abusive or threatening behaviour, patients reported little more than raised voices: "I started shouting a bit" (Patient 78). Where the patient reported losing their temper, few details were provided on what happened: "I have a temper problem and showed this bad side of me" (Patient 156). Other commonly reported factors were missed appointments and disagreement over treatment or advice. No patient account mentioned refusal of immunization or cervical screening, or the need for expensive treatment.
Comparison of doctors' and patients' views
Where appropriate, we matched corresponding factors from patient and GP surveys to compare their prevalence (Table 1). For some, such as missed appointments or demand for medication against the doctor's advice, prevalence was similar. On other issues, there was divergence, particularly ‘deception or crime’ and ‘violent, threatening or abusive behaviour’, where the high GP-reported prevalence was not matched by patient reports.
GPs and patients also reported very different levels of communication. While the majority of GPs (68%, 51 out of 75) reported warning patients that they risked removal, only 17% (13 out of 75) of patients indicated they had been warned. Similarly, 59% (44 out of 75) of GPs reported giving the patient a reason for the removal, but only 36% (26 out of 72) of patients said they had been given a reason. Of these, 71% (17/24) disagreed with the reason given. For example: "It was a convenient excuse to use me missing an appointment. Drs don't like addicts on their lists" (Patient 91).
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Discussion |
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These surveys of doctors and patients provide contrasting perspectives on recent experiences of patient removal. The GP survey is consistent with previous studies in finding that violent, threatening or abusive behaviour is the dominant reason GPs give for removing a patient.2,3,8 Verbal abuse or threats accounted for the majority of cases, with some form of physical action occurring in over a tenth of removals, findings consistent with previous work on violent behaviour in general practice.7 Many removals may be requested by GPs in order to protect their staff.
Public concern that financial incentives are significant factors are not supported by the reports of either doctors or patients in our surveys. While patients and doctors reported very similar rates of some factors, reports of abusive, deceptive or criminal behaviour were far less common from patients than from doctors and were often presented as understandable rather than unacceptable.
Our study suffers some limitations. Eliciting patient views by postal survey was problematic, and we achieved a disappointing response rate. An Edinburgh survey of removed patients reported a response rate of 26%, suggesting that low survey response may be characteristic of the population under study.4 Further, there is an inherent asymmetry in comparing the accounts of doctor and patient since the doctor is aware of the reasoning behind the removal decision, while the patient is usually not.
Our findings do not suggest any simple policy measure to prevent removals. Both patients and doctors described deteriorating relationships ending in removal, although their views on the causes differed sharply. Even if the number of removals cannot easily be reduced, a perception of poor communication contributes substantially to the distress associated with removals.9 Improved explanation before and after the event may help removed patients in dealing with the health care system and in establishing better relationships with future health carers.
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Declaration |
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Funding: This work was funded by the Department of Health. The views expressed are those of the authors and not necessarily the Department of Health.
Ethical Approval: This work was approved by the Trent MultiCentre Research Ethics Comittee.
Conflicts of interest: None.
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References |
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1 Department of Health. Terms of Service for Doctors in General Practice. London: DoH; 1989.
2 O'Reilly D, Gilliland A, Steele K, Kelly C. Reasons for patient removals: results of a survey of 1005 GPs in Northern Ireland. Br J Gen Pract 2001; 51: 661–663.[Medline]
3 Pickin DM, Sampson FC, Munro J, Nicholl J. General practitioners' experiences and views of removing patients from their lists: postal survey in England and Wales. Br Med J 2001; 322: 1158–1159.
4 Macleod L, Hopton J. A Study of the Process of Removing Patients from General Practitioners Lists. Edinburgh: University of Edinburgh, Department of General Practice; 1998.
5 Stokes T. Ending the doctor–patient relationship: an investigation of the removal of patients from general practitioners' lists. PhD thesis, University of Leicester; 2002.
6 Munro J, Sampson F, Pickin M, Nicholl J. Patient De-registration from GP Lists: and Professional and Patient Perspectives. Final report to the Department of Health. Sheffield: Medical Care Research Unit, 2002. Available at: http://www.shef.ac.uk/~scharr/mcru/reports/deregistration.pdf
7 Ness GJ, House A, Ness AR. Aggression and violent behaviour in general practice: population based survey in the north of England. Br Med J 2000; 320: 1447–1448.
8 Cummings R, Young S. Sitting pretty. Health Serv J 18 May 2000: 26–27.
9 Health Service Ombudsman. Investigations Completed: August–November 2002. 3rd Report: Session 2002–2003. London: The Stationery Office; 2003.
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