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Importance of a healthy

list size

As the new contract evolves, it is clear that patient numbers are assuming

a renewed financial significance, says Dr John Couch

When I began my career in general practice at the end of the 1970s there were many GPs around who were practising when the NHS began in 1948. Among them was my then senior partner who could hardly bring himself to speak to the senior partner at a neighbouring practice, a contemporary of his.

When I asked a colleague why this was, I was told that when GPs were all private practitioners there was huge competition for patients. A GP in one practice would imagine all sorts of skulduggery if a patient transferred 'across the road'.

This was the cause of the bad blood between them ­ my senior partner was convinced he had been a victim of poaching in the past.

The advent of the NHS only reinforced this competition as GP incomes

generally fell with nationalisation and payment was made on the basis of


As the payment systems gradually evolved, allowances were included. To a large extent these were not dependent on patient numbers so, while capitation payments continued, a proportion of income was guaranteed.

One of these, partnership allowances, further encouraged larger partnerships (most practices were singlehanded in 1948). 'Competing' with neighbouring practices became much less significant and has been little problem for my generation of GPs.

But in recent months a sense of dé vu has crept in. As the new contract evolves it is clear that the importance of patient numbers is once again in the ascendant.

New millennium, old ideas

GMS global sums/MPIG are based on patient numbers, approximately £66 per patient per annum on average. Increasingly, PMS core budget figures are also being adjusted more frequently to allow for changes in patient numbers.

Next, consider the quality framework. This accounts for around £13 per patient per annum. Clinical indicators form the bulk of QOF payments, more so in the mark 2 QOF which starts this Saturday. Every indicator is based on patient numbers/prevalence in relevant disease areas.

Finally, look at enhanced services. These currently deliver around £4.50 per patient per annum to the average practice. Payment is once again dependent on numbers of patients treated. In fact, from 1 May the new enhanced services will bring the potential to earn an extra £6.35 per patient per year, made up of practice-based commissioning £1.90, Choose and Book £0.96, information management and technology £1.33 and access £2.16. Of these the first three bring new money the only new GP funding for 2006/7.

The checking processes for all the above are strict, with electronic list-matching for core income, Qmas and practice visits for QOF, quarterly numbers reporting for old enhanced services and finally patient questionnaires/surveys for most of the new enhanced services.

In the past, the allowances system permitted list sizes to drift downwards with a buffered drop in income. Now, falling patient numbers will have a greater impact on the whole spectrum of NHS income and a large proportion of private patient fees. In effect a similar situation to 1948!

Watching the numbers

A reasonable marker is to consider every patient to be worth at least £90 per annum gross. In this way practices can judge the effects of any actual or potential changes in list size. Changes may be active a conscious decision by the practice to alter list size, or passive the result of reasons outside the practice's control.

Factors which may lead a practice to decide to allow list sizes to increase or decrease include:

·A growth area

·GP workload considered too high

·Profits unsatisfactory

·Inability to recruit (becoming less of a problem)

·Takeover opportunities.

Factors which may alter list sizes in either direction without a strategic decision include:

High numbers of GP retirements or


Expanding area but low GP ratio

High- or low-quality practice

performance/ reputation

Inability to recruit


In the brave new world discussed above, practices should review their patient numbers, workload and profits regularly at a minimum of six-month intervals. Circumstances for each practice are unique, so it is impossible to be prescriptive about this.

A practice in a rapidly growing conurbation faces totally different problems to a practice in an old established market town with a stable population, or to a practice in a deprived and dying area.

What is clear is that it will be much more difficult to have a 'selective' registration policy. Practices will be encouraged ­ or forced ­ to have lists either open to all or closed. This will create a tricky situation for those deciding to have a truly closed list.

Such practices are unlikely to get preference for development, and the vacuum created by unmet patient demand for registration may provide an entry for gathering private companies eager for a slice of primary care cake.

Whether you are looking to expand or keep a static but stable list, patient satisfaction will be paramount. Numbers matter and your list plans (and hence profits) will

depend more than ever on patients' judgment of your service. The new access enhanced service, where payment is directly linked to a patient survey, illustrates this point clearly.

In fact it is likely that practices doing well with this DES are most likely to prosper under the new system. A firm focus on good telephone access, reception staff with high-quality people skills and provision of sufficient bookable appointments will pay dividends.

What is also true is that in most areas it is easier to lose patients than to build a list up again. The same applies to that most fragile of things, reputation. Therefore, any decision to contract must be taken carefully, and any unplanned fall in list size must be taken very seriously as soon as possible.

The following example may illustrate these points.

Case history

Practice A decided to employ three part-time salaried GPs following the retirement of two full-time principals in 2004. Two salaried GPs left after a year and were eventually replaced after a succession of locums.

Patients have complained about the lack of continuity and the difficulties getting to see the partners. The list size fell from 10,000 to 9,500.

Partners' profits for 2004/5 rose by 24 per cent and are projected to rise by another 8 per cent for 2005/6. For 2006/7 profits are projected to drop by 5 per cent due to the falling list and increases in expenses without any inflationary increase in NHS income. The smaller list will cost £45,000 for 2006/7. Patient numbers are still falling. A nearby practice has seen increases in list sizes.

Here the high increase in NHS income masks a serious problem. This practice faces falling profits for some years or redundancies and increase in workload. The snowball effect of lost reputation will be difficult to turn around and the neighbouring practice will clearly profit in the medium-term.

Now imagine that a private company is allowed to set up in the area. Which practice is more likely to suffer? Whether we like it or not it is time to value our patient base more carefully. If we do not there is certainly someone else who will and, rather like 1948, we may not want to talk to them when it happens.

Bear in mind...

Review patient numbers, workload and profits regularly

·Ask yourself whether you could profitably increase list

·Provide the best possible clinical service

·Maintain good telephone access

·Employ the best-quality reception staff

·Provide enough bookable appointments

·Only contract list if deemed absolutely necessary

· Investigate any unplanned fall in list size instantly

John Couch is a GP in Ashford, Middlesex

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