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An uncomfortable erosion of trust

As cost-cutting measures go, it must have seemed like an easy win. The Department of Health’s list-cleansing drive was based on the premise that GPs were being paid for millions of non-existent ‘ghost patients’.

There was, after all, a clear discrepancy between census figures and the total number of registered patients. So what could be easier than a targeted list-validation campaign to chase the ghosts into the ether and save a much-needed £85m in the process?

Except, of course, it didn’t quite work like that. Anecdotally, GPs have reported for months that genuine patients were being caught up in draconian list-cleansing schemes. And this month Pulse’s investigation reveals for the first time just how badly PCTs have been getting it wrong.

In some parts of the country more than half those removed appear to have been wrongly struck off, and nationally in 2011/12 almost 10% of patients removed from lists ended up re-registering in the same area. It seems fair to assume there were more who didn’t bother to do so.

Cack-handed cost cutting

The impact on patients wrongly denied access to the NHS due to this cack-handed cost-cutting wheeze is very real. Some will have missed smear tests, breast cancer screening or immunisations as a result. They will have been effectively barred from GP care and will have had to make a case for reinstatement. And those most likely to have been affected are the most vulnerable: children, the elderly, migrants and those with learning disabilities.

The impact on practices, too, is not insignificant. GPs who have lost hundreds of patients overnight have spoken of the destabilising effects, and even when patients re-register it can take months to resume capitation payments.

There is another consideration too: the increasing erosion of patients’ trust in their GP.

Practices report patients wrongly removed from lists are ‘upset and angry’ – and more often than not it is the GP who bears the brunt. As one LMC leader put it: ‘They think the GP has struck them off.’

The threat to patients’ trust in their GP is also a theme tackled from a different angle by Dame Barbara Hakin in our Big Interview this month, with her seeking to allay very real concerns that potential conflicts of interest and GPs’ greater involvement in rationing decisions when clinical commissioning kicks in will place them at odds with patients. From April, GPs will no longer be able to blame service restrictions on faceless managers – they and the CCGs they comprise will be held responsible.

GPs have always balanced their role as patient advocate with the vital one of gatekeeper to the NHS. Being able to say ‘no’ to patients has always been part of the job. But being seen to limit a patients’ access to care on financial rather than clinical grounds – whether through delisting them to save the NHS cash or being party to unpopular commissioning decisions – is a very different prospect. 

The profession is being pushed into unfamiliar territory, where GPs are no longer simply patients’ carers and advocates, but have wider and at times conflicting responsibilities as the public face of an NHS seeking unprecedented efficiency savings. For many, it is an exceedingly uncomfortable place to be.