Last updated: March 2023
Purpose of this Document
ADHD Direct aims to provide the best possible health care for its patients.
However, there may be circumstances when it would be considered reasonable, or in the best interests of the patient and service staff, to remove patients from the list.
The purpose of this policy, therefore, is to define the Service guidelines for when it is reasonable to remove a patient from the practice list and to ensure that the process is dealt with fairly.
Responsibility
The Responsibility for implementing and monitoring the policy rests with the Business Manager and CEO.
ADHD Direct re-affirms its commitment to do everything possible to protect staff, patients and visitors from unacceptable behaviour and the Service’s zero tolerance of any incident that causes hurt, alarm, damage or distress.
Situations that justify removal
- Violence
When a patient is physically violent or threatening towards clinicians, service staff or other patients on the practice premises.
When a patient causes physical damage to service premises or other patient’s property.
When a patient gives verbal abuse or makes threats towards the clinicians, service staff or other patients.
When a patient gives racist abuse, verbally or physically.
When a patient is violent or uses or condones threatening behaviour to clinicians or service staff while visiting the patient’s home. Such behaviour may involve the patient, a relative, a household member, or pets (such as unchained dogs).
2. Crime and Deception
Where a patient fraudulently obtains medications for non-medical reasons.
Where a patient deliberately lies to the Clinician or other members of the Service (e.g., by giving a false name or false medical history) in order to obtain a service or benefit by deception.
Where a patient attempts to use the Service to conceal or aid any criminal activity.
Where a patient steals from Service premises
3. Embarkation
Where a patient has moved out with the United Kingdom
ADHD Direct cannot provide clinical care for patients permanently living out with the UK.
4. Failure to attend pre-booked appointments
Where a patient fails to attend pre-booked appointments on a number of occasions during a given period. This decision will be made collaboratively made by the clinical and senior management team.
5. Attempting to avoid attending medication review appointments
When patients repeatedly try to avoid attending their medication review appointments that are required following changes to their treatment. This decision will be made collaboratively made by the clinical and senior management team.
6. Failure to pay for pre booked appointments
Where a patient fails to pay for pre-booked appointments on a number of occasions during a given period. This decision will be made collaboratively by the clinical and senior management team.
7. Failure to pay for prescriptions
When a patient fails to pay for prescriptions on a number of occasions during a given period. The decision will be made collaboratively made by the clinical and senior management team.
8. Misappropriation of prescribed medications
When a patient or family does not adhere to what has been written on the patient’s prescription by either taking over and above what has been prescribed or if the prescribed medication is given to or taken by someone else. The decision will be made collaboratively made by the clinical and senior management team.
9. Failure to provide measurements for medication review appointments
When a patient or family does not provide blood pressure, pulse, weight and height (children) measurements in a timely manner or if they fail to provide measurements for two consecutive medication review appointments. The decision will be made collaboratively made by the clinical and senior management team.
10. Irretrievable Breakdown of the Clinician-Patient Relationship
Where a patients behaviour falls outside of that which is normally considered reasonable and leads to an irretrievable breakdown of the clinician/service-patient relationship
Procedure for Removal
The following procedures should be followed under each category when removal of a patient is being considered:
1. Violence / Crime and Deception
Any incident involving violence, crime or deception must be reported to the Business Manager, who will complete an incident report and bring to the attention of the CEO.
Each case will be discussed at a senior management meeting.
If a decision is taken to either warn) or remove the patient, the Business Manager will write to the patient with an explanation of the reasons for the warning or removal. After careful consideration, where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care
This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care,
In the case where patients receive private prescriptions from ADHD Direct, the service will continue to supply prescriptions for up to a maximum of a two-month period in order to give the patient time to engage with a new service provider.
The exception to this is if a patient has to be reported to the police for violent behaviour towards any member of the practice staff when she/he may be immediately removed.
If the Patient is known to be deceptive in terms of prescriptions, then the Clinician will make an informed decision as to whether the supply of private prescriptions for up to a maximum of a two-month period is or is not appropriate. The priority is safe and evidence-based prescribing, and it may be that a further prescription is not issued if the service feels that this is out with good practice or puts the Patient at risk
2. Embarkation
On notification that the patient is no longer living in the UK a letter will be sent to the patient advising of the need to reregister with a service in their area of residence within the next 30 days.
If the patient has not re-registered, or contacted the service with a reasonable explanation, within the 30-day period, they will be removed from the service list.
3. Failure to attend pre-booked appointments
If a patient fails to attend a pre-booked appointment on more than one occasion in the last year, a warning letter may be sent to the patient, advising them that a further occurrence could risk removal from the service
If the patient fails to attend another appointment, the matter will be discussed at a management meeting including the CEO and a decision will be taken as to whether the patient will be removed from the Service list.
After careful consideration where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care.
This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care.
4. Attempting to avoid attending medication review appointments
If a patient attempts to avoid a medication appointment on one occasion in the last year, a warning letter may be sent to the patient, advising them that a further occurrence could risk removal from the service. If the patient fails to attend another appointment, the matter will be discussed at a management meeting including the CEO and a decision will be taken as to whether the patient will be removed from the Service list. After careful consideration where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care. This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care.
5. Failure to pay for pre booked appointments
When patients fail to pay for a pre booked appointment once in the last year, a warning letter may be sent to the patient, advising them that a further occurrence could risk removal from the service If the patient fails to attend another appointment, the matter will be discussed at a management meeting including the CEO and a decision will be taken as to whether the patient will be removed from the Service list. After careful consideration where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care. This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care.
6. Failure to pay for prescriptions
When a patient has failed to pay for a prescription once in the last year, a warning letter may be sent to the patient, advising them that a further occurrence could risk removal from the service If the patient fails to attend another appointment, the matter will be discussed at a management meeting including the CEO and a decision will be taken as to whether the patient will be removed from the Service list. After careful consideration where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care. This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care.
7. Misappropriation of prescribed medications
This will be processed on a case-by-case basis, but depending on the severity of the misappropriation, the decision to discharge the patient immediately may be considered the most appropriate action. In less serious cases, when a patient or carer has misappropriated prescribed medication once in the last year, a warning letter may be sent to the patient, advising them that a further occurrence could risk removal from the service If the patient fails to attend another appointment, the matter will be discussed at a management meeting including the CEO and a decision will be taken as to whether the patient will be removed from the Service list. After careful consideration where it is decided to remove a patient, the Business Manager will also need to provide information to the patient on the process of continuity of care. This will involve writing to both the GP and the Patient within 7 working days with a detailed letter as to the current management plan and the options of ongoing care.
8. Irretrievable breakdown of the Clinician / patient relationship
Occasionally patients persistently act inconsiderately, and their behaviour falls outside that which is normally considered to be reasonable.
In such circumstances there may be a complete breakdown in the Clinician/Service-patient relationship.
The following steps promote good practice in such an event:
Steps to be taken within the service:
- Inform all appropriate members of the practice about the problem.
- Discuss possible reasons for the patient’s behaviour (e.g., disagreeableness, cultural differences, mental illness, personality disorder) and consider constructive steps which might avoid the need for removal
- Consider obtaining advice from HIS or any another appropriate agency
Steps to be taken with the patient:
- Inform the patient, either personally or in writing, that there is a problem
- Explain the nature of the problem to the patient
- Obtain the patient’s perspective and interpretation of the situation.
Steps to be taken if discussion fails to resolve the problem:
- Suggest that another Service might be able to satisfy the patient’s needs and expectations.
Steps to be taken in actually removing the patient:
- Inform the patient in writing of the decision and the reason for removal from the list.
- Inform the patient’s GP in writing of the decision for removal from the list, the current treatment plan and ongoing prescribing support (If appropriate) for the next two months.
- Explain to the patient the arrangement for ensuring their care is managed until they register elsewhere.
Family Members
- When a decision is made to remove a patient from the service list, the removal may well be extended to other members of the family or household.
- If this is felt to be appropriate after discussion at a senior Management level (Including the CEO).
- The Business Manager will write to the family/household offering an explanation for the removal. They will be allowed 4 weeks to re-register rather than being removed from the practice list immediately.
Exceptional Circumstances
- Where the Business Manager and CEO feel that a written explanation for the removal of a patient from the practice list could potentially endanger the safety of practice staff; a management meeting, including the CEO, will be held to decide whether the omission of a written explanation is justified.
Warning Letter
- It is essential that the patient be provided with reasons at the warning stage, along with details of the remedial action they should take if they wish to stay on the service list.
- The purpose of the warning is to give the patient a chance to change their behaviour.
Patient Removal Period
The removal will take on the eighth day after the Patient has been informed. Notification to the Patient of removal must always be in writing.
