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Taking on out-of-area patients - a quick guide to the pitfalls

Dr Richard Vautrey looks at the key issues for practices registering patients under the GP Patient Choice scheme

Practice boundaries

From January, GPs have the opportunity to register patients who live outside their boundaries without being obliged to offer them home visits.

The initiative is known as the GP Choice scheme, and it may seem attractive at first, as each patient will bring the full capitation fee when they register.

But the GPC has warned that GPs have not had time to prepare for the scheme, and there are also concerns among GPs that uncertainty about who will provide home visits and urgent care for patients who register away from home may make the scheme unsafe.

Patients registered under the scheme will not be eligible for home visits from the out-of-area practice they register with, so local area teams must arrange for this to be done by GPs local to patients’ homes. NHS England is to introduce a new national enhanced service that will pay GPs to do home visits (more information overleaf).

In September, Association of Independent Small Medical Accountants chair Bob Senior warned that practices in commuter towns were most likely to lose out under the scheme, as patients looked to register near work, and university practices might also lose out (pulsetoday.co.uk/diary). For others, such as rural practices with good access and parking, the changes might attract new patients.

This was not borne out by the pilots in 2013. It had been thought the scheme would appeal to people wanting to register at a practice near work, but a third of the practices in the pilot failed to attract any patients. NHS England admitted that it expects only 0.4% of the population to join the scheme when it is rolled out from this month.

Here, I will answer key questions about how to implement the GP Choice registration scheme safely in your practice.

What out-of-area patients can we take on? Can we pick and choose?

Practices taking on patients must do so in a non-discriminatory way. They cannot cherry-pick patients who appear relatively well.
However, practices are allowed to refuse to register patients when they believe they have care needs that would be better met through registration with a practice near to where they live. These might be patients who are receiving a package of home or community-based support that would be difficult for the practice to co-ordinate remotely or where there are child or adult safeguarding concerns. The practice will have to clearly explain to the patient why they are not able to register them.

If a practice accepts an out-of-area patient it must make clear what the terms of the registration are, and how patients can find out how to obtain urgent care if they are unable to travel to the practice by contacting NHS 111. Patients should also be warned that if their health circumstances change, making out-of-area registration clinically inappropriate in the future, they could be removed from the list (although regulations to make this possible were not in place at the time of writing).

Should we undertake any extra steps when registering a patient from outside our practice area, such as making a note on their records?

Practices should keep a list of which patients are registered with an out-of-area status, and make it clear on their records too. This will help them to give these patients clear information about the risks and limits of registering under this scheme and will also help the practice respond appropriately to requests from these patients in the future, and monitor whether it continues to be clinically appropriate to continue with this arrangement.

How should we inform patients about the consequences and limits of being registered as an out-of-area patient?

There is a model letter at Annex D in the guidance (available at pulsetoday.co.uk/access). Patients are advised to contact NHS 111 if they need urgent care and are unable to travel, or if the practice cannot deal with their problem over the phone.

How much funding will we get under the scheme?

According to the guidance released on 11 November 2014, NHS England intends to pay practices the same global sum (GMS) or baseline (PMS) funding, as well as any other payments (such as QOF or enhanced services income) for out-of-area-registered patients as they would for a local registered patient.

But this may change in the future. NHS England has said it may reduce the capitation fee for patients if, after six months of the scheme, data show urgent care costs need to be offset. However, it will discuss such changes with the GPC.

What steps should we take if we want to refuse out-of-area patients?

There is no obligation for practices to register out-of-area patients, or offer to provide home visits to local patients registered out of the area.
Practices can already register patients living outside the area and offer them the full range of GMS, including home visits when necessary. They do not need to participate in the new scheme to do this.

But if you do decide to participate, make it clear via your patient leaflet, website or other information areas whether you are accepting out-of-area registrations or not.

If local patients move away can they automatically become an out-of-area patient?

No. You can keep the patient (but still do home visits), deregister the patient (because they have moved outside the boundary), or re-register them as an out-of-area patient. GPs can only refuse continued or new registration on clinical grounds (for example, if the patient is too far away to be cared for safely).

Can students register as out-of-area patients?

No. Students should be registered in the current way and if they need care when they return home they should then be seen as temporary residents. The GP Choice scheme is not designed to be a dual registration system and it would not be appropriate for students to register near their place of study and at home.

Can we refuse to let our own patients register at another practice?

No. Practices cannot prevent their patients registering with another practice. It is for patients to decide who they register with and whether they want to register as an out-of-area patient or not.

Do we have to provide a home visit if they we know that an out-of-area patient does not have access to a home visiting service?

No. The local area team or CCG has a responsibility to commission a home visiting service. If local practices do not want to take up the DES, the area team or CCG can invite another practice to do it or seek an alternative provider.

If GPs are worried a patient may not yet be covered by a local home visiting service, they should refuse to register them on the grounds that it would not be clinically appropriate. GPs are not obliged to check whether a patient is covered but this can be done by calling NHS 111.

Dr Richard Vautrey is deputy chair of the GPC.

 

References

1 GMS Contract 2014-15

2 NHS England. Choice of GP practice. Guidance on the new out of area patient registration arrangements

3 NHS England. In-hours urgent primary medical care enhanced service. 2014

 

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Readers' comments (6)

  • It seems an awful lot of hassle for not much income at all.
    The communication problems with the "home" surgery make it not worth doing.
    It'll encourage wasteful doctor shopping and duplication of effort.
    And fraud perhaps, as patients demand CD's and other med's from different practices with no efficient means of communication, other than time consuming telephone calls and faxes of recent records.
    Is GP2GP ready for this? What we have already looks pretty limited to me.
    Patients should get a life and take time off work to look after their health.

    Not doing it.

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  • Vinci Ho

    The more you look at this , the more questions are raised. Patients can be easily confused about what they are entitled to have and this can be potentially a recipe of medical accident and complaint. Safety becomes an issue if the local GPs signed up the DES visited an ill patient registered with a practice near his workplace far away, as the local GPs had no prior knowledge or access of information about the patient.

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  • What has happened to the concept of a 'Medical Home' - just coming into fashion in the US?

    I imagine the patients who want to register close to their place of work will be the ones with chronic problems requiring monitoring rather than those with no problems at all: is there any information from the pilots about the type of patient who registers out of area?

    How does in-area care work? Do practices register to be available, or is the patient regarded as a temporary resident, able to call on *any* practice - and complain if not seen immediately as an emergency?

    The whole scheme appears to be somewhat muddled...

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  • We're not doing ay of this cobblers.
    We await out forst complaint from a patient that has registered away and we refuse to see as we're not part of the DES.
    I can see the ethical dilemma and the daily mail headline!

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  • Wouldn't touch it with a barge pole.......as with new guidelines for Dementia diagnosis and the Friends & Family test, the politicians have exercised their egos and created more unnecessary, poorly thought out policy aimed at vote winning.

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  • I can see all the concerns.

    However, in many places in the western world this is normal practice. I worked in Canada as a GP and in our town there were approximately 5000 patients yet we had 15,000 patient records. We were paid on a fee-for-service basis. And patients frequently came to us for another opinion.

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