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List cleansing hits the most vulnerable

Too often schemes place savings ahead of patients or practices, says Dr Tony Grewal

Too often schemes place savings ahead of patients or practices, says Dr Tony Grewal

The wording of the NHS regulations describing the so-called ‘FP69' process is pretty innocent. The regulations, known as the ‘green card' process to my generation, go like this: where the address of a patient on the contractor's list is no longer known to the primary care organisation, then it will ‘give to the contractor notice in writing that it intends, at the end of the period of six months, to remove the patient from the contractor's list of patients', and ‘at the end of that period, remove the patient from the contractor's list of patients unless the contractor satisfies the PCO it is still responsible for providing essential services to that patient'.

However, this statement fails to capture the true essence of what has become more widely known as ‘list cleansing'. The original intention, to avoid paying GPs for ghost patients, has been subsumed into a welter of other agendas, which pose risks to practices and vulnerable patients.

NHS management assumes ‘list inflation' is a given, and that all practices are overpaid. Many statistics are adduced to justify this, but the chief culprit is the last national census, whose raw population numbers are compared with GPs' registered lists – the obvious resulting disparity fuels any number of initiatives to deregister patients.

Even if practices confirm patients have been removed who are still at their registered address and wish to continue receiving services from the practice, capitation payments will not resume until the following quarter, when hundreds, or in some cases thousands, of patients have been deducted from each practice – allowing PCOs to make substantial savings in their primary care budgets.

Problems encountered over the past few years in London include the failure to deliver mail or only sending one letter, addressing letters to ‘the occupier' at multiple-occupancy dwellings and only writing in English. FP69 flags have been entered when a letter is simply unanswered, and in large numbers at one time. Issues with the software have made it hard to identify ‘flagged' patients on computer systems, no help at trusts is available for patient queries and there are ludicrous requirements for justifying retention or restoration of patients to the list – including requiring copies of computer records to confirm recent contact and refusing to accept that patients not seen over as little as six months may be genuine.

Taking the blame

Patients often fail to understand that their deregistration is not at the behest of the practice. The most vulnerable patients, particularly the elderly, those with mental illness and those with poor or no English, are most likely to end up without a GP and risk missing important screening and health promotion opportunities. Small practices may not have the resources to chase up hundreds of patients. New or obtuse computer systems may preclude practices taking early and effective action.

LMCs and practices need to be alert for initiatives from PCOs or the new PCT clusters, particularly if initiated by external agencies. Londonwide LMCs has produced a list of principles that may help practices in dealing with this latest threat:

• rolling programmes over at least two years

• no targeting of a few practices at a time

• letters addressed to named patients, not to ‘the occupier'

• information to be provided in the top 10 languages in the area

• a dedicated help line (with translation facility) for patients

• practices' declaration that a patient is still receiving services at that address to be sufficient evidence

• PCOs to provide training on identifying ‘flagged' patients on GP computer systems.

Ghost patients are of no benefit to practices, and we should welcome a proper list-validation programme. However, the current initiatives are designed to extract money from practices and endanger patient health and practice viability.

Dr Tony Grewal is a medical director of Londonwide LMCs and a GP in Hillingdon, west London

List-cleansing: the backstory

In March 2011 we reported that up to 40% of patients could be stripped from practice lists within months under an unprecedented list-cleansing drive by NHS managers; read more here.

Dr Tony Grewal

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