How can I manage our patient list to cope with workload?
Pulse outlines the ways practices can control their list size to help cope with workload
Our practice is overwhelmed and we can’t cope with any more patients. What can we do?
There are four main options. You can apply to close the practice list formally, or suspend new registrations on an informal basis. Other options are to remove patients who live further away, or shrink your practice area.
How do we close our list formally?
Under GMS/PMS contract regulations, practices can apply in writing to their NHS England area team, or equivalent body in the devolved nations, to close the practice list formally. To do this you must follow the procedure outlined in the relevant paragraphs of the regulations.1,2
The BMA advises you can do this on the grounds that workload is jeopardising your ability to provide safe care, or to carry out your contractual obligations to meet patients’ core clinical needs.2 However, before applying you should first:
- Try negotiating staffing support with other services;
- Document what other options you’ve considered and their outcomes – whether rejected or implemented;
- Speak to your LMC;
- Also speak to neighbouring practices and ask for help – documenting outcomes;
- Meet with the area team/health board, accompanied by an LMC representative;
- Discuss with your patient liaison group and take on board suggestions.
If approved, the closure will be permitted for a maximum of 12 months, or until an earlier date once the number of patients falls below an agreed figure.
A practice can apply to extend closure beyond the agreed period, following the same procedure, but must do this no less than eight weeks before the closure is due to end.1
What if we have our application turned down?
There is no specific formal appeal process, but practices can dispute the decision through the generic contractual dispute process – the NHS Dispute Resolution Procedure. However, Pulse understands this would likely require you to demonstrate that the commissioner had not properly followed the regulations in making its decision.
You can apply again to close your list formally, but not within three months of the initial rejection, or at the final decision if you dispute it unsuccessfully.1 You could, however, make a further application sooner if circumstances changed affecting your ability to deliver services.
What is the informal route?
According to the BMA, practices have the right to decline new registrants without getting approval from NHS England/health boards, under regulations that state you can refuse patients if you have ‘reasonable grounds’ and do so on a non-discriminatory basis.3 The BMA argues reasonable grounds can be protecting the quality of patient services under for example, excessive workload, or lack of staff capacity.
Although you don’t have to give official notice, you must provide patients with written notice. The BMA advises you put up notices and provide patient leaflets explaining you are temporarily unable to accept any new registrations and why. Importantly you should not refer to a ‘closed’ list, however – only say that you are currently unable to take new patients.
The downside to this informal approach is that it may not be enough to stop your area team/board from continuing to allocate you new patients. You may be asked to justify why you won’t register a new patient, in which case you need to be able to demonstrate you are not discriminating on any grounds – the BMA advises that having a written acceptance policy in place will help to demonstrate that any refusal is not down to discrimination.
If you find you are routinely unable to accept new patients you should speak to your area team/board to seek additional support, or apply for formal list closure.
Can we come to a mutual agreement without the formal list closure process?
NHS England has sanctioned an informal process whereby commissioners can agree to a temporary period – usually three months, but sometimes longer – during which a practice does not accept new patients. This is done on a discretionary basis. It means the practice avoids taking a unilateral decision to stop taking on new registrants, which the commissioner may not recognise.
The process is outlined in Chapter 5.2 of the NHS England primary care policy manual, including what circumstances the commissioner should consider a temporary suspension – such as a sudden, unexpected loss of staff or surge in demand, an event such as flooding, or an unfavourable CQC inspection.4
Pulse understands practices in the devolved nations may be able to come to a similar mutual agreement with health boards, although there is no specified procedure as in England.
Can we be penalised, for example by being refused enhanced services?
No. According to the BMA, a previous reference to reviewing enhanced services has been removed from the regulations, in recognition that this would be discriminatory to existing patients, and prevent practices from managing a safe list size and workload while still providing holistic, enhanced care to their patients.
Could we take on out-of-area patients in that case?
No. If the list is closed you may not take on any other patients, including any wishing to register under the out-of-area scheme, except, for example, immediate family members of registered patients where it is in the patients’ best interests to be registered at the same practice.
Can we remove patients from our list?
The BMA says you should only do this as a last resort, after exploring all other avenues for managing list size and workload. As above, you have to be able to justify this course of action and make sure you do not discriminate against any patient groups. You could consider excluding:
- all out of area patients
- only those lying outside of the outer boundary (if relevant)
- out of area patients residing beyond a certain distance
- patients outside the boundary and beyond a certain travelling time for home visit.
However, be mindful that removing patients is likely to get you bad press locally. The BMA advises consulting patients or the PPG, your area team, the CCG and the LMC to ensure patients have alternatives. Communication and getting people on your side is key – which could involve your local MP.
If you do decide to go down this route, you must follow the regulations on removing patients from your list, outlined in paragraph 20 of Schedule 6, Part 2 of GMS regulations.1
Can we reduce the practice catchment area?
Reducing your practice area is the other option to help bring workload down to safely manageable levels.
However this will need to take wider issues into account – it requires a variation in contract and therefore the agreement of the area team/health board, depending on what other GP services are available and the impact on other practices.
1. National Health Service (General Medical Services Contracts) Regulations 2004. Schedule 6, Part 2, Pars 29–31
2. National Health Service (Personal Medical Services Agreements) Regulations 2015. Schedule 2, Part 3, Pars 32–34
3. BMA: Quality first – list management
4. NHS England primary care services manual; November 2017: Chapter 5.2