Dilemma: A patient moves but doesn't want to deregister
A very anxious and dependent patient who has complex medical needs has been registered with the practice for many years but is now moving five miles outside your practice area. He is desperate to stay on your list and states ‘I won’t call you out for any home visits’. You feel inclined to keep him on your list in view of his various problems but your partners are less keen.
It is not appropriate to continue to register a patient unless all contractual services, including home visits, can be offered.
To ensure partnership consistency, and avoid patient uncertainty, all practices should follow a clear policy to manage these requests. Not all PCTs have insisted on submission of a formal ‘outer’ practice boundary, but one should be maintained internally if a practice does permit continuing registration outside the current boundary. To avoid potential accusations of discrimination, favouritism, and unreasonableness the practice policy should use local geographical features and be reviewed regularly. I would recommend special provision for terminally ill patients to maintain continuity of care.
This patient’s request should be managed in accordance with current established practice processes, so it is not appropriate to continue to register a patient unless all contractual services, including home visits, can be offered.
The patient should be advised of the decision made by the partnership, emphasising this is a consistently applied policy, and offered support to re-register if necessary.
Dr Julius Parker is a GP in Slough and chief executive of Surrey and Sussex LMCs.
Don’t wait for a situation to arise in which the patient needs a home visit, but your practice can’t look after them.
The question is, are they moving within the practice’s outer boundary? Since the middle of last year the new regulations have stipulated that practices should have an inner and outer boundary. Most patients will live within the inner boundary but if a patient moves a short distance - between the inner and outer boundary - having these rules helps them to remain on the practice list.
But five miles is usually way outside any practice’s outer boundary, unless they’re in a rural area in which case it’s unliely they’d have an outer boundary anyway. The issue then is that you’re not in position to pay them any home visits without causing disruption to practice routine, and therefore it’d be detrimental to the service you normally offer all your patients. That’s why practices choose to have these boundaries.
In our LMC, we have given advice on this topic on an individual basis. Our general recommendation is for a practice to establish an outer boundary for consistency and fairness. You shouldn’t keep patients on if they move outside outer boundaries.
Suggest to the patient that he or she registers elsewhere. While it’s understnable that the GP might be concerned about the future care of this patient, it is inevitable that some patients will move outside your area – and you’ve got to be realistic about how best to support them if that happens. Don’t wait for a situation to arise in which the patient needs a home visit, but your practice doesn’t have the capacity to look after them.
Chris Locke has been Chief Executive of Nottinghamshire LMC since 1996.
Explore his concerns about leaving the practice, and reassure him that you will do all you can to ensure a smooth transition to another practice.
Practices place restrictions on the area from which they will take patients for good reasons. Whilst you may be sympathetic to the patient and wish to accommodate him, you have to balance your responsibilities to him against those of your other patients. Although well-intentioned, the patient is not in a position to make decisions over home call-outs, particularly in the light of his complex medical needs and, in any event, you could not enforce this. If you decide to keep this patient on, he would be entitled to expect the full range of services available to all other patients of the practice, regardless of where he is living. You also need to consider the potential impact on the service as a whole, and the implications for your partners, who are less enthusiastic. It may not be in his best interests that you agree to his request, as this may simply reinforce his dependence on you as his healthcare provider. You should explore his concerns about leaving the practice, and reassure him that you will do all you can to ensure a smooth transition to another practice.
Dr Janet Page is a medicolegal advisor at the Medical Protection Society.