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We have been denied permission to close our list. What should we do?

My practice has been denied permission to close its list to new patients as we cannot cope with our current list. Can we appeal this decision? Is there anything else we can do to avoid taking on new patients?

Dr Mohammed Jiva - online

Dr Mo Jiva: Ask NHS England for help

Is your problem shared by other practices across the locality and, if so, how are they responding?

Liaise with NHS England (or your primary care organisation in the devolved nations) and make managers aware of your concerns about the viability of the practice if the list continues to grow. Invite representatives to the practice to discuss the issues to ensure they see the problems first hand.

Ultimately, if the practice is sinking to the point of becoming unviable and managers refuse your request to close the list, you could discuss a merger with a neighbouring practice. If NHS England or the PCO does refuse then appealing is likely to have little impact.

In the meantime, review your workload and decide what services can be stopped, especially if they are not resourced (for example, enhanced services and private medicals). Then review your system for appointments and consultations and assess whether there is a more efficient way to address the increasing patient demand. You might consider telephone triage; would a local out-of-hours provider be willing to triage patient calls for the practice?

Work out how patients can safely be triaged and redirected appropriately to other local primary care services, for example, opticians, pharmacists, self-help groups and charities.

See if any of your back-office functions, such as payroll or audits, can be devolved to other agencies in order to free up staff time to meet patient demands. Do you need to engage locums to help you to gain control of existing workload? If so, estimate how many more sessions you will need them for.

Dr Mohammed Jiva is the secretary of Rochdale and Bury LMC and a GP in Manchester

 

Dr Paul Roblin

Dr Paul Roblin: Seek ‘open but full’ status

The GMS regulations on closing a practice list can be found at paragraphs 29 and 30 of the GMS regulations.1 Although there have been amendments since then there is no collated up to date document and the changes have not altered the essence of the sections on list closure (for ‘PCTs’ just substitute the local area team of NHS England). Paragraph 30 deals with rejection of an application and permits a practice to invoke the NHS Dispute Resolution Procedure.

A practice faced with intolerable patient demand can use paragraph 17 of the regulations permitting non-acceptance of a patients registration requests:

Refusal of applications for inclusion in the list of patients or for acceptance as a temporary resident: the contractor shall only refuse an application made under paragraph 15 or 16 if it has reasonable grounds for doing so which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.2

For ease of naming, using this paragraph is often known as ‘open but full status’ and, to be legal this has to be done in the non-discriminatory way it is written.

Recently there has been discussion about whether this paragraph can still be used. Pulse reported in January 2012 that the Government had announced it was to abolish ‘open but full’ GP practice lists as it set out further details of how it will road-test the removal of practice boundaries and expansion of patient choice. But paragraph 17 still exists in the contract and we call its use when practices experience excessive demand. So far as I know, rejection of its use in this way has never been tested.

Commissioning authorities do not like this term but its proper use has never been successfully challenged and it does provide some immediate respite for practices where the official procedure described above winds its normal slow route to conclusion.

Dr Paul Roblin is the CEO of Berkshire Buckinghamshire and Oxfordshire LMC.

References

1 GMS contract paras 29-30. http://www.legislation.gov.uk/uksi/2004/291/schedule/6/paragraph/29/made

2] GMS contract. http://www.legislation.gov.uk/uksi/2004/291/schedule/6/paragraph/17/made

 

Harry Yoxall - online

Dr Harry Yoxall: Talk to the LMC

The practice’s first step should be to talk to the LMC. If the decision has been made by a relatively junior staff member at the local area team or PCO, a call from the LMC chair to the director may solve the problem. If not, the LMC can pursue the matter through formal channels. As this may take time, it is worth seeking help when the problem is first recognised and before it has become intolerable.

The last thing the area team or PCO wants or needs is to have to find primary medical care at short notice for several thousand unsettled patients.

You and an LMC representative should also arrange to sit down and talk to the director of primary care about how to make sure that the practice can continue to provide safe care for its existing list. And there may be solutions without closing the list. But the practice needs immediate support as well as longer-term help in exploring all the options.

Don’t forget that your patients can be your greatest allies. Tell them and all your staff that the practice is struggling to provide a full service, why this is, and what you are doing to make things better. Many will be able to offer support if you need to make your argument public.

It is clear if workload is not controlled then it is only a matter of time before both GPs and staff begin to run into serious difficulties, and in the current climate there is a real risk that once one domino falls the rest will follow.

Dr Harry Yoxall is the medical director of Somerset LMC

 

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Readers' comments (8)

  • It also depends why the surgery is looking to close their list. If physical space is the constraint, try talking to your landlord about a redevelopment to increase capacity.
    If the practice is a freehold, there are a number of active investors who may be able to provide capital and expertise to grow the practice.

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  • yeah right but at the end of the day if they say no then you are still stuffed.................NHS England etc do not know what the real world and workload is about...................

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  • My understanding is that the "open but full" rules still apply. You cannot be required to breach the requirements of Good Medical Practise by compromising clinical care. GPs are required to "put themselves in a position to make a diagnosis", and "to offer a service which meets at least the average performance of his or her GP peers". By having too large a list size, you would be at risk of breaching this principle.

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  • Turn people away without discrimination. Make exceptions for newborn babies.

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  • De .ar Dr Robin, Thank you for that enlightening note about the 'open but full' option. Any tips about ' to be legal this has to be done in the non-discriminatory way it is written'.

    Would it suffice to say that - the list is open but full due to inability to provide services to more patients. This policy does not discriminate against anybody and is applicable to all.
    My application for list closure is in the pipeline and and hence the concern. Thanks once again for informing about this option.

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  • Marlowe Park Medical Centre:
    We have been refused list closure too.
    Reasons given:
    -We have not provided evidence; Fact- NHSE official proposed dates and did not turn up to consult or discuss options. Decision given after 8 weeks of application.
    - We are not underfunded : Fact: the whole MPIG was taken off in one stroke and increase in list size by almost 1000 patients resulted in increase of total payments via OpenExeter by 28000 pounds annually between 2009 and March 2014.
    - We have not explored employing an Advanced Nurse Specialist instead of GP as that is affordable. Fact: Over my dead body ( probably that will happen:) - I don't trust compromising quality is an option - who is to blame for her errors?
    - I am supporting a GP who needs supervision and thus wasting my time; Fact- immoral to even put that as a reason- This is the third reminder to avoid helping a GP who the Trust wants to strike off.
    Conclusion: If you have people in NHSE who with hands in pockets snarl at GPs in the presence of passive LMC officials in meetings: 'You are finished Dr X, you are finished, You watch me mate.' - you surely can't expect quality or understanding for your excessive workload. Morever, if the Commissioners are people who do a survey amongst patients and in meetings arrogantly repeat 3 times 'they ' don't have to listen to people' they ' don't care what people say', you realize that the NHS is rotting top down
    Welcome to Kent and Medway - the vague patch of England.

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  • I would stop registering any more patients, making sure I did it on a non discriminatory basis. I would do this to protect the health of my staff and my existing patients.

    If I was asked, I would explain in writing what and why I was doing it. I would have a list size in mind that I wanted to achieve, and would start taking on patients again if I dipped below that.

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  • I am a GP in Tower Hamlets and our practice has been burdened with this problem. There is an inherent flaw in the model of having to take on all patients in your practice area, a Kafkaesque & Herculean task scenario. The trouble is that Hercules was a superhero, and we are modest humans (hence the Kafkaesque nature of the problem).

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