The first results of the 2011 census showing an apparent rise of three million in the UK population will not come as a surprise to most GPs. Doctors have never been convinced by the argument that practice lists are artificially high because there are more people registered as patients than listed on the electoral role.
There are many reasons why individuals may not be counted in a census. Although in 2011 a great effort was made to minimise those, there is a steady turnover of the population of the UK, with many new arrivals not registering with a GP until they need medical care – which roughly balances the number of people who have left the country without telling their registered practice.
Although this group of new patients does not currently make any demands on general practice, the whole capitation system is based on the assumption that the care of those who need it most is mainly paid for by the capitation income to the practice from infrequent users of the service. It is therefore essential that practice lists genuinely reflect the real number of patients who are able to call on their services.
Now that all UK residents have access to the same NHS primary care as British citizens, practices have little scope for raising revenue from private charges. With a rising proportion of the UK population coming from overseas, especially from other EU countries, the financial stability of each of our practices will increasingly depend on ensuring that these people join our lists. Historically, high levels of registration have also ensured that everyone has access to healthcare – and preventive medicine – and many PCTs have previously worked with GPs to increase registration(?) rates among UK residents originating from other countries.
As part of the preparatory work for the transfer of English PCT responsibilities to the local teams of the NHS Commissioning Board, PCT clusters have been instructed to ensure that GP practice lists are accurate and many have been undertaking list-cleansing exercises. CCG funding will depend on the number of patients registered with their constituent practices when they launch, so getting it right is important at this level too.
The GMS contract states primary care organisations should ‘prepare and keep up to date a list of the (practice’s) patients’. The way they do this is using the FP69.
If the family health services agency of a PCT believes that a registered patient may no longer be resident at the address recorded on the patient demographic service, they will contact the practice and give notice that the patient will be removed from its list in six months unless the practice can, in that time, show it is still providing essential services to the patient concerned.
PCOs have always sent out letters to patients sporadically, asking if they are still resident at their recorded address when, for example, a screening invitation letter is returned or undeliverable. The current list-cleansing programme has led some to send mass mail-outs to larger numbers of patients, which initially seems to show that as many as 10% of registered patients are ‘ghosts’.
Patients may not respond to letters for several reasons. Some are illiterate. Some just do not reply to official-looking letters, perhaps frightened that their immigration status will be questioned. Some may have gone abroad for a while but have plans to return, and some may just not be able to understand written English.
As a minimum, letters from PCTs to patients should be written in plain and clear English, with a sentence or two in the more commonly used foreign languages in the area explaining how to obtain a translation, with a clear statement that the letter comes from the NHS and not any other government agency.
At best, the practice then has to track down the patient and confirm that he or she is still living in the practice area. Often this is not possible until the patient contacts the practice itself – and if the patient has been removed, then at least three months’ capitation income will be lost.
At worst, some of the most vulnerable patients will have been arbitrarily excluded from NHS primary care for bureaucratic reasons.
Dr Harry Yoxall is a GP in Taunton and medical director of Somerset LMC