Whether you know it as list validation, list cleansing or the FP69 process, at the end of the day most GP practices have experienced some kind of list-cleansing scheme first hand.
Most of us would agree that checking our patient list is essential to provide honest, good-quality care to the public. It is also important to have clean lists to ensure accurate funding. Where payments are based on achieving a percentage target of patients – with the QOF, immunisations and cervical screening, for example – a clean list means that your denominator is smaller. Any activity that affects practice budgets may also be skewed by ‘ghost' patients obtaining services elsewhere.
If you take the regulations on list cleansing at their word, it is hard to see a problem. But the issue really lies in the way in which the process is implemented.
Many GPs find list cleansing can be time-consuming, frustrating and confusing. It can also divert scarce resources to explaining and apologising to patients who have been wrongly removed.
As a medical director for Londonwide LMCs, I am often heavily involved in negotiating how the process is undertaken. We have worked hard to put in place agreed boundaries to ensure list cleansing is implemented in a clear and fair manner, such as rolling programmes over two years.
At the moment, we know that GPs in several parts of the capital – including Lewisham, Southwark, Lambeth, Bexley, Bromley, Greenwich, Barnet and Haringey – are sifting through FP69 requests.
Here are five checks I'd recommend to any practices who are faced with a list-cleansing exercise or who suspect there may be one in the pipeline:
1 Ensure patient details are correct and up to date
There is no requirement for GPs themselves to manage lists, other than to inform their primary care organisation (PCO) if a patient has died or is leaving the country for three months or more.
It is important to banish the myth that GPs knowingly leave ‘ghosts' on their lists – there is no significant profit in it and it would leave a practice at risk of a fraud allegation. Making sure you have good contact details for patients in the first place will help ensure they don't get knocked off your list during the FP69 process.
Think ahead and always get reception staff to check patients' home address every time they make contact with the surgery – if possible, try to keep their contact number up to date as well.
In my years as a GP and as an LMC medical director, I have seen a broad range of foul-ups that have made what should be a simple process a complete mess, for practices and patients alike. Many of the issues arise with the communication to the patient. We have experienced:
• undelivered mail
• patient letters only sent out once
• letters sent without the individual's name on the envelope.
The non-delivery rate can be up to 25% in London. Having an up-to-date address for patients will help reduce the undelivered mail problem.
2 Be ready when the request comes
The NHS regulations describe the FP69 process like this: ‘Where the address of a patient who is on the contractor's list is no longer known to the primary care trust/local health board', it will ‘give to the contractor notice in writing that it intends, at the end of the period of six months commencing from the date of the notice, to remove the patient from the contractor's list of patients; and, at the end of that period, remove the patient from the contractor's list of patients unless within that period the contractor satisfies the primary care organisation it is still responsible for providing essential services to that patient'.
If you receive an FP69 Prior Notification Transaction from your PCO or NHS Shared Business Services, don't put it to the bottom of the growing pile of tasks, act quickly – time can fly by. Reception staff and practice staff can also proactively anticipate list cleansing by watching out for warnings and advice from LMCs in email alerts and newsletters.
3 Check your list for FP69 flags
Once you have been informed that a list-cleansing drive is under way, actively access your clinical systems to check for flagged patients. Your PCO should be able to show the practice manager how to do this, but if not then contact your system provider or ask colleagues at your local practice managers group. GPs and practice managers are not expected to flag patients themselves, but should know how to find them on patient files.
4 Keep patients informed
Tell patients when a FP69 process is taking place and remind them to keep the practice up to date with changes to their address and phone numbers.
There are many ways to effectively raise awareness of a list-cleansing drive among staff and patients. Some examples include posters and leaflets; notices in local papers, welfare offices, Citizen's Advice Bureaux and libraries; and messages on repeat prescription slips.
In some boroughs, Londonwide LMCs has negotiated a system where the PCO sends a list of patients not recently in contact with the practice to GPs, to allow them to remove any patients identified as vulnerable before the main list-cleansing mail-out is dispatched. Your area might benefit from a similar system.
Another issue has arisen whereby PCOs only write to patients in English, even though a growing proportion of patients – especially in London – do not speak English as their first language, if at all. There is little or no support from PCOs when it comes to patient queries and rarely much advice for practices either.
5 Help patients re-register
The main concern for GPs in this process is our patients. We know that those most in need of our care are, in fact, those most likely to find themselves deregistered and the most likely to be distressed and confused by this – the elderly, the mentally ill, those who have limited grasp of English and other vulnerable patients. If patients are removed from your list and are upset, provide them with the name and address of the relevant PCO contact to complain to and re-register them. It may help to give them a slip, explaining what has happened and that it is not the practice's fault. They might also not have the right ID with them to re-register at the time, so remind them they will need to bring documentation next time they visit the surgery.
In the capital, Londonwide LMCs has given practices information about who has responsibility for this and, where we have agreed list-maintenance processes, we have asked the PCTs to provide patients with a contact for enquiries and concerns.
Dr Tony Grewal is the medical director of Londonwide LMCs and a GP in Hillingdon, north-west London