The removal of patients from doctors' lists causes considerable public and political concern, with speculation that patients are removed for inappropriate, including financial, reasons.1 In 1999 the House of Commons Select Committee on Public Administration noted that little evidence was available on either the frequency of, or the reasons for, removal of patients.2 National statistics do not distinguish between patients removed after moving out of a practice area and those removed for other reasons. Two postal surveys have reported why general practitioners might, in general, remove patients,3,4 and one small study has described the reasons doctors give for particular removals.5 We therefore determined the current scale of, and doctors' reasons for, removal of patients from their lists in England and Wales.
Participants, methods, and results
In April 2000 we sent a questionnaire to 1000 general practitioners in a random sample of practices, but to no more than one doctor per practice. Up to two reminders were sent to non-respondents at fortnightly intervals.
The questionnaire asked for the number of patients removed from the practice list in the previous six months (for reasons other than living outside the practice area), the reasons contributing to the most recent removal, and whether that removed patient was given a reason. A list of suggested reasons for removal was included (having been compiled in the light of published opinions3,5), and respondents were asked to indicate which of these were “primary” reasons and which others were “contributory.”
The questionnaire also asked whether target payment systems (for childhood immunisation and cervical smear testing) and financial arrangements for drug budgets and out of hours care created financial incentives for removing patients.
Of the 1000 doctors surveyed, 14 replied that they were not working in general practice. Of the remaining 986, 748 (76%) responded. In the previous six months 300 out of 745 practices (40% (95% confidence interval 37% to 44%)) had removed one or more patients. When 21 practices whose list size was not stated were excluded, 988 patients had been removed during this period from a registered population of 4.6 million, (removal rate of 4.3 (4.1 to 4.6) per 10 000 patients a year).
The primary and contributory reasons given for the most recent removal by each of these 300 practices are shown in the table. Violent, threatening, or abusive behaviour was given as a primary reason in 176 of 300 removals (59% (53% to 64%)) and as a contributory reason in a further 24 (8%). Other primary reasons given were complaint by a patient (5 (2%) cases), non-compliance with childhood immunisation (4 (1%)), and non-compliance with cervical smear testing (2 (7%)).
In 238 of 288 (83% (78% to 87%)) most recent removals, the practice had given the patient a reason for the removal, either in writing (55% (157)) or in person (28% (81)).
About half of general practitioners believed that the target payment systems for childhood immunisation (370/732) and cervical smear testing (360/732) had created financial incentives to remove patients. Smaller, but still substantial, proportions of respondents considered that financial arrangements for practice drug budgets (295/728) and out of hours care (321/733) also created such incentives.
Comment
General practitioners report that violent, threatening, or abusive behaviour by patients is their most common reason for removing a patient from their list. Non-compliance with childhood immunisation or cervical smear testing was rarely reported as a reason, and never as the sole reason, for removal despite the perceived financial incentives for removal.
The validity of our findings depends on doctors being able and willing to identify and report the number of removals and their reasons for them. If our respondents were unaware of all removals from the practice or were not truthful about why they removed patients, our findings will misrepresent the situation. Moreover, patients may have different views of the events leading to removal, which future research should seek to understand.
Table.
Primary and contributory reasons given by 300 practices for most recent removal of a patient from their list. Values are numbers (percentages) of practices citing each reason
| Reason | Primary | Contributory |
|---|---|---|
| Violence, threats, or abuse | 176 (59) | 24 (8) |
| Drug or substance misuse | 36 (12) | 51 (17) |
| Inappropriate demand: | ||
| In normal hours | 38 (13) | 47 (16) |
| Out of hours | 24 (8) | 31 (10) |
| Inappropriate demand for medication | 31 (10) | 54 (18) |
| Non-compliance with: | ||
| Appointments | 38 (13) | 39 (13) |
| Treatment | 25 (8) | 44 (15) |
| Childhood immunisation | 4 (1) | 5 (2) |
| Cervical smear testing | 2 (1) | 5 (2) |
| Deception or crime | 44 (15) | 26 (9) |
| Complaint or litigation by patient | 5 (2) | 14 (5) |
| Inappropriate sexual behaviour | 7 (2) | 6 (2) |
| Request for unconventional treatment | 3 (1) | 6 (2) |
| Cultural differences | 3 (1) | 3 (1) |
| Request for particular kind of general practitioner | 2 (1) | 4 (1) |
| Other | 11 (4) | 3 (1) |
Some respondents gave more than one primary reason or more than one contributory reason per removal.
Acknowledgments
We thank Stuart Drage, Peter Corpe, and Bernard Horan for their valuable advice and assistance.
Footnotes
Funding: This work was funded by the Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health.
Competing interests: None declared.
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