Dr Ravi Mene knows the real cost of list cleansing. In the past three months alone, he has had 20 patients come to his small, inner-city practice in Manchester demanding to know why they had been struck off his list by overzealous PCT managers.
The process has led to ‘unpleasantness and heartache’ for local GPs, he says, with most unaware why patients have been removed and unable to explain.
He says: ‘Patients aren’t notified when they’re taken off the lists. Some only find out when they turn up.’
Dr Mene is not alone. Currently, PCTs are chasing 2.5m so-called ‘ghost patients’ across England to cut costs. But Pulse can reveal tens of thousands of them are anything but ghosts and may be very much in need of ongoing GP care.
List-cleansing schemes are nothing new, of course, and have always been run by individual PCTs at a local level. But the national drive launched in 2011 is of an entirely different scale.
Anecdotally, GPs have complained that the drive is heavy-handed – and now for the first time a Pulse investigation reveals that a large number of genuine patients are being kicked off lists.
In some areas over half of those removed from lists are genuine patients, while some programmes explicitly target the most vulnerable patients, including those with learning disabilities, the very elderly and children.
Their primary language is not English – so they didn’t bother reading the letters
Dr Ravi Mene
In Dr Mene’s area, the figures are broadly representative of those across the whole country. NHS Salford removed 1,331 patients from practice lists in 2011/12 and 2012/13. Of these, 149 re-registered in the same PCT area, suggesting that 11% had been erased in error.
Dr Mene says patients living in multi-occupancy homes were targeted in his area, and were left bewildered at being deregistered.
‘Their primary language is not English – so they didn’t bother reading the letters,’ he says.
Figures obtained by Pulse from 53 PCTs under the Freedom of Information Act reveal some 2,611,958 patients have so far been reviewed. Of those, 6% were removed from practice lists.
Across the 24 PCTs able to give full data, 9.8% of the 41,119 patients removed from practice lists turned out to be genuine patients and were forced to subsequently re-register in 2011/12. Extrapolated across the country to all 152 PCTs, this would mean more than 25,000 patients had been wrongly removed. The equivalent proportion is 7% so far in 2012/13.
In some areas, the numbers are higher. NHS Airedale, Bradford and Leeds reported a 13% re-registration rate, while in NHS Blackburn and Darwen a clear majority of patients – 55% – re-registered.
NHS managers claim they are following the guidelines for list cleansing and have ‘robust procedures’. Debbie Nixon, locality director for Blackburn with Darwen Care Trust Plus, says patients were given ample opportunity to confirm their registration – and claims practices are also responsible.
She says: ‘In addition to writing to patients on a number of occasions, GP surgeries are advised to make contact with the patients over a six-month period after concerns are raised.’
A spokesperson for NHS Salford says: ‘The key objective of list validation in Salford is to ensure more accurate lists so that important information, such as screening letters and results, is received by the people it is intended for, thereby increasing patient safety.’
But GP leaders fear that over-enthusiastic list cleansing will harm patient care, with many likely to miss crucial check-ups after being cut adrift from the NHS.
PCTs began large-scale list-cleansing schemes as part of QIPP cost-saving initiatives, and the Department of Health set trusts a target of delisting 2.5m patients by April this year in the NHS Operating Framework for 2012/13.
This was to correct the discrepancy between the total population in England in 2011 (52m) and the number of patients on GP lists (55m). Guidance urged NHS managers to target immigrants, the elderly, students, pupils in residential schools and multi-occupancy dwellings to reduce list inflation.
Many PCTs employed companies to cleanse lists for them, writing to certain groups asking them to confirm they still lived at the specified address and removing them if they did not respond.
The predicted cost savings for the whole project were substantial. The DH estimated reducing ‘list inflation’ by an average of 3% would save £85m.
The average patient costs £64.67 in global sum payments – a boon to managers seeking easy cost savings before handing over to CCGs in April.
‘Not fit for purpose’
Dr Richard Vautrey, deputy chair of the GPC, says GPs appreciate the need for list validation, but not the ‘heavy-handed’ approach seen in some areas.
He says: ‘The blanket approach taken by PCTs has affected genuine patients, losing their registration with their GP.
‘We have brought it up with the Government on many occasions, but it seems blind to the problems it’s creating.
‘It must be done in an appropriate way – 55% of patients re-registering in some areas is a sign of how poorly PCTs have gone about the task, how they’ve placed patients in unacceptable situations.’
The Government seems blind to the problems it’s creating
Dr Richard Vautrey
He adds that simply sending letters is a poor method of ascertaining whether patients should remain registered: ‘When patients receive things that they don’t understand, they ignore them. If information were provided in more appropriate ways they might respond.’
Dr Barry Moyse, chair of Somerset LMC, says: ‘The process is not fit for purpose. In Somerset, there are large numbers of Portuguese workers who were “cleansed” and had to re-register.
‘This is too important for a bureaucratic contact. The letters are not prominently marked – they should say something like “Your GP registration depends on this letter” instead of just looking like a Reader’s Digest circular.’
The list validation drives could put patients’ health at risk, he warns: ‘It’s risky – patients taken off lists will miss invitations to smear tests, breast cancer screening and immunisation.
‘It’s theoretically possible that patients with long-term conditions could not have access to medicines – though in practice this probably wouldn’t happen. It’s throwing the baby out with the bathwater.’
All this creates real tension between patients and practices. Last year a report by the Parliamentary Health Ombudsman found a 16% rise in complaints from patients ‘unfairly’ removed from practice lists. At the time, the RCGP queried whether the number of patients being unfairly struck off by GPs was being confused with patients removed as a result of PCTs’ list-cleansing drives.
A spokesperson for the ombudsman told Pulse it was ‘confident’ this was not the source of the increase, but GPs say they are often blamed by patients.
Dr Tony Grewal, medical director at Londonwide LMCs, says GPs in the capital report between 5% and 20% of patients removed from lists are re-registering.
He says: ‘Patients who can’t read, have mental health issues or are vulnerable in another way don’t understand it’s not something the GP has done; they think the GP has struck them off.
‘So GPs have to spend considerable time explaining that it’s a PCT drive and it’s not done by the GP in malice.’
He adds that practice cashflow is also being hit. He says: ‘If a patient is removed from your list, you lose capitation. If they re-register, the capitation payments don’t come in until the next quarter. So you lose capitation for two quarters for a patient who thinks they’re registered.’
A single model?
The DH is clear that taxpayers should not fund ghost patients and that the programme will continue from April.
‘It is unfair to expect taxpayers to pay for patients who are no longer receiving services from a practice,’ a spokesperson says. ‘Before people are removed from GP lists, they must be contacted and given ample opportunity to confirm they are still in the area.’
But with the NHS Commissioning Board due to take charge of the programme, the DH says it hopes it will take a ‘more appropriate approach’ than simply focusing on costs.
The NHS Commissioning Board says it is looking at developing a ‘single model’ for list validation to replace the plethora of systems currently used by PCTs.
‘The NHS Commissioning Board will, on 1 April, inherit from PCTs a range of arrangements for maintaining the accuracy of GP practice lists,’ a spokesperson says.
‘The board will want to draw on the best of current practice to develop a single model that is fair for practices and for the patients they serve.’
But Dr Mene is unconvinced that this will make a difference. He says: ‘We’re in difficult times – and we don’t know what will happen when the CCGs come in.’
Who are PCTs targeting?
• Men aged 25 to 50 years
• Residential schools
• Multi-occupancy houses
• People over 100 years old
• Patients registered at hostels
• Patients registered at demolished-property addresses
• Children still registered some months after their parents have been removed from the GP list
• Addresses with undelivered letters from screening and vaccination programmes
Source: FOI responses