Pulse’s newest investigation revealed new data on the number of practices applying to close their patient list – a last throw of the dice before handing back their contract. As part of this series, Eliza Parr explores why GPs might instead take an informal route to ‘close’ their list
When workload becomes unmanageable and potentially unsafe, making a lengthy application to formally close the patient list may not be the best option for GP partners. Not least because rejected applications are becoming increasingly common.
An ‘informal closure’ is much simpler – a GP practice decides to stop registering new patients, and doesn’t need to get explicit permission from their local commissioner.
However, this route may not stem demand quite so successfully, as ICBs can continue to assign patients to the practice and override any informal measure in place.
Whichever the measure, the factors leading GP partners to breaking point are often very similar: an influx of new patients due to housing developments, difficulties recruiting GPs, high demand, or local practices shutting up shop.
A Pulse survey of 405 GP partners earlier this year showed that 5% had informally closed their list – more than the 3% who had done so formally. According to Freedom of Information data obtained by Pulse, the Suffolk and North East Essex ICB area saw 15 informal closures over the five years from 2018 to 2022. This is five times more than the number of formal closure applications – none of which were accepted by the ICB.
Is it allowed?
Unlike applying for a formal closure, the informal route isn’t explicitly detailed within the GMS contract. Some GP partners told Pulse they weren’t entirely sure whether closing their list without going through the formal process is even allowed.
But the BMA has been clear – practices can take ‘informal list measures’ and this is still within the independent contractor’s rights. The contract says practices can refuse applications for inclusion in the patient list if they have ‘reasonable grounds’. It’s not entirely clear what these reasonable grounds might be, and the contract does not mention safe working or workload pressures. However, the BMA told Pulse it would not consider taking these measures to be a breach of contract, and it is not aware of a remedial notice ever having been issued for this reason.
Indeed, in some areas informal list closure has been promoted – earlier this year Leicester, Leicestershire and Rutland (LLR) LMC advised its practices to do so if they feel unable to provide a safe service.
For those considering this option, there are some important safeguards to bear in mind. The contract guards against discrimination – practices must not make refusals based on grounds related to age, appearance, disability or medical condition, pregnancy or maternity, race, religion or belief, sexual orientation or social class. And they must also inform patients of the rationale for refusing the registration application. Ensuring these clauses are followed could be crucial in preventing any contractual issues with the local commissioner.
Although permission from commissioners is not essential, the BMA advises practices to consult with them, and doing so could result in some extra support. The union also tells practices to raise the matter with their patient participation group (PPG).
The key difference between formal and informal measures is the fact that the ICB or health board can continue to assign patients to the list. Practices may find themselves having to justify their decision to refuse a patient registration. And in Scotland, GP partners need to be careful not to refer to their list as ‘closed’ if they haven’t been through the formal process – instead their public statements must simply say they cannot currently take on more patients.
One GP partner in Didcot, who wishes to remain anonymous, says they didn’t formally close but all new patient applications ‘went through the ICB’. ‘It doesn’t make much difference but just means as the ICB are assigning they are necessarily aware of the issues – they don’t seem to take on much responsibility for local patient services otherwise,’ she adds.
So taking the informal route can help to raise awareness with the ICB about the pressures a practice is under, without needing to go through a formal process.
Does it work?
One GP partner in South East England says they closed to registration, accepting only allocations, for around seven months. The practice had lost a GP and had difficulty recruiting a replacement. There had also been new housing built in the area with ‘absolutely no support from the ICB or NHS England’ and no ‘accompanying resources’.
‘Ultimately general practice is a business and is being starved with increasing relentless demand – this approach was a last resort,’ the GP partner says. Closing the list informally helped to manage these pressures in the interim, while also avoiding the ‘long winded’ formal application.
In Merseyside, a group of practices took a collective approach to closing their lists. Out of four practices in the locality, one of them started experiencing access and staffing problems, leading to patient frustration. Patients started to leave and looked elsewhere – one GP partner at a neighbouring practice says they started to get new patient applications ‘in numbers we couldn’t absorb’.
‘So the three practices in the locality coordinated an informal closure where we didn’t register new patients if they already had a GP within the area. If they’d moved into the area from elsewhere, we accepted those patients. But not if they were moving from practice to practice in the same area.’
While the ‘place’ team within the ICB was aware of, and even supported, this temporary measure to help practices stay afloat, the GP partner says there should be a more robust mechanism in place. The practices have had to open and close the list multiple times throughout the year, responding when new registrations climb up again.
‘Ideally, we would all agree to take “x” number of patients per month. If there had been a mechanism where we could take a number that we felt comfortable with, then we wouldn’t have had to close on and off.’
At a national level, a limit on unmanageable list sizes doesn’t appear to be on the agenda. Earlier this year, the Government rejected a recommendation by MPs on the Health and Social Care Committee to examine the possibility of a maximum list size of 2,500 patients.
The informal route therefore seems an imperfect lever for practices experiencing persistent problems with capacity. It is by nature only temporary, and when registration opens again, demand can shoot back up.
Without proper resourcing, practices cannot hope to resolve the underlying issues which result in list closures, formal or informal. While it may provide a short reprieve, some practice will find that closing their list ultimately doesn’t move the dial.
Read more about list closures in our ‘No room at the practice’ series
