Dr Mo Jiva: Ask NHS England for help
Is your problem shared by other practices across the locality and, if so, how are they responding?
Liaise with NHS England (or your primary care organisation in the devolved nations) and make managers aware of your concerns about the viability of the practice if the list continues to grow. Invite representatives to the practice to discuss the issues to ensure they see the problems first hand.
Ultimately, if the practice is sinking to the point of becoming unviable and managers refuse your request to close the list, you could discuss a merger with a neighbouring practice. If NHS England or the PCO does refuse then appealing is likely to have little impact.
In the meantime, review your workload and decide what services can be stopped, especially if they are not resourced (for example, enhanced services and private medicals). Then review your system for appointments and consultations and assess whether there is a more efficient way to address the increasing patient demand. You might consider telephone triage; would a local out-of-hours provider be willing to triage patient calls for the practice?
Work out how patients can safely be triaged and redirected appropriately to other local primary care services, for example, opticians, pharmacists, self-help groups and charities.
See if any of your back-office functions, such as payroll or audits, can be devolved to other agencies in order to free up staff time to meet patient demands. Do you need to engage locums to help you to gain control of existing workload? If so, estimate how many more sessions you will need them for.
Dr Mohammed Jiva is the secretary of Rochdale and Bury LMC and a GP in Manchester
Dr Paul Roblin: Seek ‘open but full’ status
The GMS regulations on closing a practice list can be found at paragraphs 29 and 30 of the GMS regulations.1 Although there have been amendments since then there is no collated up to date document and the changes have not altered the essence of the sections on list closure (for ‘PCTs’ just substitute the local area team of NHS England). Paragraph 30 deals with rejection of an application and permits a practice to invoke the NHS Dispute Resolution Procedure.
A practice faced with intolerable patient demand can use paragraph 17 of the regulations permitting non-acceptance of a patients registration requests:
Refusal of applications for inclusion in the list of patients or for acceptance as a temporary resident: the contractor shall only refuse an application made under paragraph 15 or 16 if it has reasonable grounds for doing so which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.2
For ease of naming, using this paragraph is often known as ‘open but full status’ and, to be legal this has to be done in the non-discriminatory way it is written.
Recently there has been discussion about whether this paragraph can still be used. Pulse reported in January 2012 that the Government had announced it was to abolish ‘open but full’ GP practice lists as it set out further details of how it will road-test the removal of practice boundaries and expansion of patient choice. But paragraph 17 still exists in the contract and we call its use when practices experience excessive demand. So far as I know, rejection of its use in this way has never been tested.
Commissioning authorities do not like this term but its proper use has never been successfully challenged and it does provide some immediate respite for practices where the official procedure described above winds its normal slow route to conclusion.
Dr Paul Roblin is the CEO of Berkshire Buckinghamshire and Oxfordshire LMC.
1 GMS contract paras 29-30. http://www.legislation.gov.uk/uksi/2004/291/schedule/6/paragraph/29/made
Dr Harry Yoxall: Talk to the LMC
The practice’s first step should be to talk to the LMC. If the decision has been made by a relatively junior staff member at the local area team or PCO, a call from the LMC chair to the director may solve the problem. If not, the LMC can pursue the matter through formal channels. As this may take time, it is worth seeking help when the problem is first recognised and before it has become intolerable.
The last thing the area team or PCO wants or needs is to have to find primary medical care at short notice for several thousand unsettled patients.
You and an LMC representative should also arrange to sit down and talk to the director of primary care about how to make sure that the practice can continue to provide safe care for its existing list. And there may be solutions without closing the list. But the practice needs immediate support as well as longer-term help in exploring all the options.
Don’t forget that your patients can be your greatest allies. Tell them and all your staff that the practice is struggling to provide a full service, why this is, and what you are doing to make things better. Many will be able to offer support if you need to make your argument public.
It is clear if workload is not controlled then it is only a matter of time before both GPs and staff begin to run into serious difficulties, and in the current climate there is a real risk that once one domino falls the rest will follow.
Dr Harry Yoxall is the medical director of Somerset LMC