PRACTICE LETTERHEAD			

			

			

Name and Address to be added 

Date to be added

Dear 

We value you as a patient and want to continue to provide you with high-quality care.  However, your current contact with the Practice is disproportionate to your health needs and is impacting upon our ability to provide an equally responsive service to all our patients.

So that we can continue to help you address your health issues and to manage your clinical needs, we need to set some boundaries and expectations that will foster an effective relationship between you and the Practice.
 
In order to do this, we have drawn up an agreement’ that outlines the behaviour we will expect from you. In return, we will make every effort to accommodate you and your needs, as well as being clear on what you should be able to expect from us.

Please review the agreement carefully. If you would like to meet with us to discuss the agreement and your ongoing care in more detail, please contact XYZ on XXXXXX and she will arrange a mutually convenient time for us to meet at the Practice.

Yours sincerely

Dr XYZ
On behalf of the XYZ Surgery

XYZ SURGERY

PATIENT/PRACTICE AGREEMENT

This agreement is between ______________________ (name/relationship to the patient, if applicable) and ___________________ (Practice name). 

In an effort to better care for __________________________(patient name and NHS number), the following expectations are required from           (patient name) to maintain an effective and responsive Practice–patient relationship. 

Behaviour Expectations 
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
5. ___________________________________________________________________________________

(Examples of expectations: this may include how the patient addresses/speaks to staff, how often appointments are made and their duration, the system the patient should follow for booking appointments, how new or urgent clinical issues are managed, who the main point of contact for the patient is (administrative and/or clinical), how consultations are conducted (eg only bring 1 or 2 issues to the appointment, do not revisit previous issues unless relevant, do not behave aggressively etc)

If the Practice has a leaflet/policy, that sets out what patients can expect from the Practice, it is useful to attach it or to include several bullet points in the Contract covering what the patient should expect from the practice (eg appointments will last approximately 10 minutes, routine appointments will normally be available within x days, who the patient’s nominated GP will be, what will happen if that GP is not available etc)
 
Initial 

1.	______ I have read and understand the above-listed behavioural expectations. I also understand that failure to meet these expectations may result in my removal from the Practice’s registered list.

2. ______ I have received a copy of the practice’s Complaints policy. 

Patient/Family/POA signature: _______________________ Date:_________________ 

Practice signature: _________________________ Date:_________________ 

Witness signature:_________________________________ Date:_________________

Agreement review date: