GP practices have been told they must consider patients’ neurodivergence and learning disabilities before removing them from their patient list under the special allocation scheme (SAS).
The advice follows a change to NHS England guidance and a coroner’s prevention of future deaths report.
The coroner’s report into the death of a 33-year-old Devon man ‘in crisis’ identified his removal from his GP practice and subsequent placement on the special allocations scheme as ‘possible contributory factors to the deterioration in his health’.
It found that the scheme – which is typically used when a patient has been violent – was unable to fulfil the health needs of the man, who was on the autism spectrum.
As a result of the report, NHS Devon said it now requires written confirmation from practices that they have ‘considered all possible alternative approaches’ before removing patients from their lists.
In the time between the man’s death and the release of the coroner’s report, NHS England changed its guidance to require GPs to take into consideration learning disability and neurodiversity prior to making an SAS referral. NHS England said this change was unrelated to the death.
The prevention of future deaths report, which was sent to organisations including NHS England and NHS Devon ICB in March this year, said the man’s allocation to the SAS had not appropriately met his needs.
In Devon ICB’s response letter to the report, sent in May this year, it said it had modified its SAS procedures ‘following receiving this prevention of future deaths notice’.
It said: ‘We have determined to make a modification to the Special Allocation Scheme Standard Operating Procedures that specifically requires written confirmation from practices that they considered all possible alternative approaches to providing primary medical services prior to making the placement’.
GP contract regulations state practices can remove a patient from its list immediately if ‘the person has committed an act of violence against any of the persons specified in subparagraph (2) or has behaved in such a way that any of those persons has feared for their safety’.
HM Senior Coroner Philip Spinney said: ‘(The man) was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme.
‘This scheme was not able to meet the needs of a patient … with a diagnosis of Autism Spectrum disorder.’
The report requested that patients allocated to the scheme ‘are properly assessed as being suitable for the scheme and receive the appropriate clinical care and treatment’.
A spokesperson for NHS Devon said: ‘The case has been reviewed extensively, and we know that there are lessons that can be learned to improve this process in future.
‘We welcome the coroner’s recommendations and have issued new guidance to local practices asking them to make additional considerations when determining whether to place someone on the special allocation scheme.’
In its response letter, NHS England said that at the time of the incident its primary medical services policy and guidance manual (PGM) did not advise GPs and commissioners to consider learning disability or neurodiversity when referring patients to SAS.
It referred to guidance updated last year which says GP practices ‘will need to confirm that prior to removing the patient from their patient list they have carefully considered patients’ protected characteristics and key past medical history, learning disability and neurodiversity and the practice has completed any safeguarding considerations where applicable’.
It also included: ‘An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services.’
NHS England said these assessments ‘would be subject to consideration when new services are commissioned or when existing services are reviewed’ but also subject to ‘funding availability.’
Commenting on the changes, Professor Azeem Majeed, head of the department of Primary Care and Public Health at Imperial College London, said: ‘The decision to refer a patient to the SAS is a serious one and rightly requires careful consideration.
‘However, in practice, such decisions often need to be made rapidly and under difficult circumstances.’
Professor Majeed said while the ICB’s additional requirements and NHSE’s updated guidance are ‘well-intentioned’, they could be ‘challenging to implement in urgent situations’.
‘Primary care teams already work under considerable time and administrative pressures, and adding further bureaucratic steps could delay referrals or discourage appropriate use of the scheme; thereby potentially putting staff and other patients at risk.
‘There needs to be a balance between safeguarding patients’ rights and ensuring a swift response when serious incidents occur’, he said.
‘Ideally, the process should allow for urgent referrals in exceptional circumstances, with more detailed documentation and review to follow once the immediate risks have been managed.
‘Support from ICBs and NHS England will be essential to ensure that practices understand the requirements for referral to the SAS and can implement them safely and effectively.’
NHS England explanation of changes to SAS referral guidance
The PGM was updated on 15 July 2024 to include the following key updates in the SAS section:
a) Remind GP practices of the need to undertake careful considerations prior to referring a patient into the scheme, having considered the patient’s protected characteristics, past medical history, learning disability and neurodiversity.
b) Implement a prompt to GP practices when completing the online referral on the need for careful consideration (Status: in the process of implementation).
c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability.
At the time of (the patient’s) death, a previous version of the PGM was in effect that did not include these items. The PGM available at the time (and still present in the current version) includes guidance on ‘behaviours this scheme does not ordinarily cover’.
Paragraph 7.4.14 of the PGM states:
“consideration should be given as to the history and circumstances of a patient including:
• wherever the behaviour can be ascribed to a condition capable of being rapidly alleviated by treatment, eg mental health illness or medical/acute conditions with known behavioural changes (eg head injury)
• whether it relates to a patient who has never been aggressive before and/or who is clearly suffering mental or physical distress
• careful consideration of any mitigating circumstances must be given as to whether a referral to the scheme is in the best interests of the patient.”
Source: NHS England response to Regulation 28 Report to Prevent Future Deaths
A version of this story first appeared on our sister publication Pulse.
