Written evidence from the Permanent Secretary, Department of Health
FORMULA FUNDING OF LOCAL PUBLIC SERVICES
At the Public Accounts hearing on 12 September 2011, Committee members asked for a note from the Department of Health on the work programme to improve and maintain the accuracy of GP patient lists.
Below I set out (1) the background (2) the differences between estimates and actual GP registrations (3) action taken to date and (4) Proposed next steps.
The NHS (General Medical Services Contracts) Regulations 2004 and NHS (Personal Medical Services Contracts) Regulations 2004 place an obligation on primary care trusts (PCTs) “… to prepare and keep up to date ...” a list of patients accepted by each GP contractor. Subject to the Health and Social Care Bill, this obligation will be transferred to the NHS Commissioning Board from April 2013.
These patient lists form the basis for certain payments to GP contractors. GP registrations also feed into the calculation of PCT allocations and are likely to be a key element in the future allocations formula for clinical commissioning groups, subject to the passage of the Health and Social Care Bill.
When calculating PCT allocations, GP registrations are constrained to Office of National Statistics (ONS) resident populations. This means that PCT populations sum to the ONS estimated population for England, and this ensures that PCTs total allocations are not over-funded as a result of inaccurate GP patient lists. For PCT allocations, reconciliation of lists to ONS populations is also undertaken below the national level. However, inaccurate lists will affect the relative distribution of funding across small areas and thereby reduce allocative efficiency.
Inaccurate lists also cause inequities in the funding of GP practices. At the aggregate level, payments to GP contractors (which are ordinarily set on the basis of recommendations by an independent pay review body) take into account data on overall earnings and expenses. So, to the extent that list inflation causes increases in aggregate GP practice income, this may over time be taken into account indirectly in setting fees. But this does not in any way reduce the importance of ensuring the accuracy and fairness of payments to individual GP contractors.
Active list management by PCTs is, therefore, essential to seek to maintain accurate GP patient lists through the removal of inappropriate patient records such as those for deceased patients, “gone-aways” and duplicates.
2. DIFFERENCES BETWEEN ONS ESTIMATES AND ACTUAL GP REGISTRATIONS
Comparisons of ONS population estimates and GP list populations are used as a way of assessing the potential scope of practice list “inflation”. There are a number of potential justifiable reasons for differences between ONS estimates and the number of actual GP registrations, including:
¾ The current ONS population figures are estimates based on the Census of 2001, updated for each year since then taking into account a number of assumptions. Given the significant length of time since the 2001 Census, it is possible that the latest estimated population figures are not accurate.
¾ Prisoners who have been sentenced to less than two years imprisonment are legitimately permitted to be registered twice, by remaining registered with their “home” GP practice and also with the practice providing prison medical services.
¾ There is a time lag when patients move practice between being registered at a new practice and being removed from their old one.
ONS has recognised the need to improve its population estimates, particularly in relation to international migration, and commenced a programme of work several years ago, the Migration Statistics Improvement Programme. This work is ongoing and continues to feed into improved population estimates. International migration is likely to be more significant for London where list variation is greatest. The results from the 2011 Census will provide much more up to date comparisons between the number of GP registrations and ONS estimated populations.
However, these reasons are insufficient to explain fully the difference of 2.5 million in the total number of GP registrations and the estimated population of England, and the proportionately greater disparities seen in some areas. The Department and the NHS therefore undertake a range of actions to improve the accuracy of GP patient lists.
3. ACTION TAKEN TO DATE
The Audit Commission undertake a regular National Duplicate Registration Initiative (NDRI). The 2004 NDRI exercise, which reported in 2006, concluded that, as a result of that work, 185,000 patient records across England &Wales were cancelled (0.3% of the population), saving over £9.5 million.
The NDRI was initially undertaken in 1999 and again in 2004 and 2009. The latest review is currently underway and is due to be published in November 2011.
The Initiative is carried out as part of the statutory audit of PCTs. It uses data matching techniques to review GPs’ patient lists to identify inaccuracies. Matches are fed back to National Health Applications and Infrastructure Services (NHAIS) sites, which manage patient list data for all PCTs. These NHAIS sites investigate the matches and where appropriate the patient’s registration is cancelled. The Audit Commission itself does not carry out any investigations.
The aspects of patient data that the Commission examine include:
¾ Deceased patients—GP lists have been matched to DWP data to identify deceased persons who remain on GP lists;
¾ Duplicates—where both records appear to relate to the same person;
¾ Multiple occupancy households—where there is a large number of patients registered at a single common address; and
¾ Removed asylum seekers—where UK Border Agency data show individuals who have been deported from the country, but whose names remain on GP lists.
The majority of GP Payment Agencies (working with their PCTs) have now finished reviewing their NDRI matches and, where appropriate, have taken action to cancel patient registrations. It is anticipated that thousands more patient records will have been cancelled as a result of this work, improving GP list accuracy and saving more NHS resources, though it will be necessary to await publication of the Audit Commission report before the final numbers are known.
The Department is considering how best to undertake independent duplicate registration initiatives in the future after the abolition of the Audit Commission.
Department of Health
The Department of Health has also been pro-active in seeking to ensure that the accuracy of GP patient lists is improved. There are a number of strands to this approach.
Most recently, the Department of Health wrote to strategic health authorities (SHAs) in November 2010 to encourage them, their PCTs and Payments Agencies to do more to improve the accuracy of GP patient lists. This letter pointed out that, if those PCTs with the largest differences between total GP registered lists and ONS estimated populations were to reduce the difference between the two to the England average of 5%, then that would save the NHS some £46 million across England.
Following discussions with officials in the Department, NHS Primary Care Commissioning (an NHS organisation that provides contracting advice to PCTs) circulated a briefing note to all PCTs in July 2010 to outline the benefits of list cleaning.
Since these initial letters, the Department has held regular discussions with SHA primary care leads to ensure that PCTs continue to keep a focus on ensuring accurate patient lists.
4. PROPOSED NEXT STEPS
The work of actively managing GP lists to ensure they are accurate is an ongoing task owing to the changing nature and movement of practice populations, including as a result of births, deaths, emigration, immigration and population movements within the country.
Informed by the findings of the latest NDRI exercise, when they are available, the Department is planning to undertake a diagnostic exercise aimed at identifying:
¾ any PCTs that have still to carry out meaningful action to address potential inaccuracies in local GP practice lists;
¾ PCTs that have made progress, but could do even more to address the issue of list cleaning, based on what they have done already compared to any remaining apparent disparity between GP lists and the ONS population in their area; and
¾ PCTs that have had the greatest success at improving the quality of their GP patient lists and whose experience may be utilised to support other areas.
NHS Commissioning Board
As set out in “Developing the Commissioning Board” published on 8 July 2011, the NHS Commissioning Board will (subject to Parliamentary approval of the Health and Social Care Bill) become responsible for commissioning of primary care services from April 2013.
We envisage that the NHS Commissioning Board will adopt a single operating model for commissioning of primary care services, including list validation. Following on from the diagnostic exercise undertaken by the Department, it is expected that the Board (when established) will continue to work through local Payment Agencies to improve list cleaning activities. The Board will be able to draw on the NDRI work undertaken by the Audit Commission and to look at how national IT systems can be improved to facilitate regular data matching that will support list cleaning.
We are also exploring how the NHS Commissioning Board can use the proposed authorisation process for clinical commissioning groups to reinforce the importance of accurate patient lists as the basis for allocations to clinical commissioning groups, notwithstanding the fact that the legal responsibility for list accuracy rests with individual GP practices and the relevant commissioner.
As PCTs will remain responsible for commissioning of primary care services throughout 2012-13, we are also exploring how to ensure that PCTs give sufficient operational priority to list cleaning during that year, prior to clinical commissioning groups taking on their own budgets.
I hope that this information provides the information that Committee members require.
20 September 2011