The SAS scheme specifically deals with patients who have committed an act of violence or has behaved in such a way that any of those persons have feared for their safety. The ICB accepts that the violence does not have to be physical or actual, it can be perceived, threatened or indeed a perceived threat of violence. The overarching objective behind the SAS is to ensure any patient removed under the violent patient regulations has access to essential and additional medical services.
“The regulations require that, for a patient to be immediately removed from a practice list, the practice must report the incident to the police. The 14-point process is designed to work in all but very exceptional circumstances. Those infrequent and exceptional cases relate solely to commissioner instigated allocations (e.g. a patient that falls within the remit of a SAS allocation, but with no recent removal from a GP practice) and must be discussed and agreed with the commissioner in advance.
For further information: Primary Medical Care Policy & Guidance Manual (PGM)(V5), page 55-57, 7.1-7.5.16
Note: practices should be reminded of the statutory requirement to notify the Care Quality Commission (CQC) about any incident related to their service that is reported to or investigated by the police.
The practice is required to notify the ICB via PCSE and by using the online forms via the PCSE website, which are available here. The practice must also notify the patient that it has requested their removal from the patient practice list.
To request removal of a patient from your practice list (either immediate or within eight days), you must follow the correct procedure. Information about patient removals, the relevant forms and what happens if an SAS patient tries to register with a practice can be found on the PCSE website here.
The SAS may require urgent medical information from the GP practice upon initial referral and this may necessitate a clinician-to-clinician discussion between the referring practice and the SAS provider.
Under the SAS, designated GP practices will provide services to patients by prior appointment and at specific locations and times as detailed in individually agreed contracts.
The local SAS is currently provided by Essex Partnerships University NHS Foundation Trust under an APMS contract. The service provides GP led primary medical care services for patients who have been subject to immediate removal from a practice list because of threatening or violent behaviour.
The Regulations regarding the removal of patients who are violent is specific in terminology.
The Health Circular 2000/01 defined violence in the primary care context as: “Any incident where a GP, or his or her staff, are abused, threatened or assaulted in circumstances related to their work, involving an explicit, or implicit, challenge to their safety, wellbeing, or health”.
To ensure that Your LMC Executive Officer is able to act effectively as your advocate we need to be in receipt of information about the incident which led to a patient being removed from the practice to the SAS, as well as relevant information from the scheme in support of their recommendation to remove patients from the scheme and return them to general practice.
To facilitate this we are asking that if you currently have, or if in the future you apply to remove a patient under the violent patient regulations you send us an anonymised copy of your completed PCSE form (but do include the patient NHS number) by emailing it to [email protected] Lisa will then be able to liaise with you about the case and act as your advocate at panel meetings.
SAS panel meetings
The scheme administers quarterly patient review multi-disciplinary panel meetings. The purpose of which is to:
- Review all new referrals to the Scheme to ensure referral is appropriate and, if yes, agree a holistic individual care plan for the patient whilst on the Scheme
- Review individual patients by the panel at least every six months.
After removal, all patients must be allocated to and accepted by the ICB commissioned SAS, at a SAS Panel meeting. Subsequently, all patients allocated to SAS will be reviewed by the SAS panel, every 12 months and, if the review panel feels the behaviour of the patient is no longer threatening or aggressive, the patient should be able to register with a GP practice of their choice if they live within the practice boundary.
There are currently quarterly SAS review meetings where potential removals and new additional patients are discussed and added or removed from the SAS. The ICB will circulate a list of patients being considered for removal and addition to the scheme a minimum of 2 weeks prior to the scheduled review meeting. Attendees at the meeting include the ICB, LMC, NSFT, and the SAS provider. On receipt of this information the LMC, SAS representative will contact all practices within Norfolk & Waveney who have been identified as the removing practice to ascertain the reason behind the removal and if the patient is still within the practice area how the practice would feel about the patient returning to the practices care. This is subject to the patient showing remorse, behaving appropriately whilst on the scheme and agreeing to behave when they return to general practice, the patient is advised that should they misbehave when they are returned to general practice that they will automatically be returned to the SAS.
When an SAS patient’s review takes place, and the patient is deemed to be ok to return to general practice, both the patient and their prospective practice should be notified directly by the ICB/SAS Provider.
If a patient on the SAS approaches your practice to re-register, without the practice having received confirmation from the ICB that they have been released from the scheme, the patient should be asked to contact the SAS Team.
If the behaviour of one member of a household or family has led to their removal, this does not mean that the removal of other family members should automatically follow. An explicit discussion, whilst protecting the confidentiality of the removed patient, with other family members about the problem and the doctor’s concerns will often obviate the need for any further action.
In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to look after the whole family. This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members as patients could put doctors or their staff at risk.
The LMC and GPC would suggest that reasons are given clearly in the case of a removal. The practice should always consider how it would look to outside observers if a family were to be summarily removed from the list in haste and without explanation for a single misdemeanour or disagreement with one family member.
Further guidance is also available at the BMA – Removing violent patients and the SAS and the BMA -Removing patients from your practice list.
BMA practice list validation guidance
For further information: Primary Medical Care Policy & Guidance Manual (PGM)(V5), page 55-65, 7.1-7.5.16