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The real problem with ‘ghost patients’ is what’s actually scary

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I read with incredulity that the NHS Counter Fraud Agency are to investigate whether GP practices are using so-called ‘ghost patients’ to fraudulently claim capitation fees.

It has long been recognised that there are more patients registered with English general practice than appear on the census. The issue of ’ghost patients’ is not new. What is new is the suggestion that practices are deliberately claiming for ghost patients in order to drive up their income.

The number of ‘ghost patients’ varies from area to area. Our team at the Universities of Manchester and York looked in detail at the factors associated with ghost patient numbers. Our study, published last year in the Journal of Epidemiology and Community Health, was a cross-sectional analysis of the national GP patient list and census-derived population estimates. We calculated levels of patient registration with English general practice, in relation to census derived data in order to work out the number of ‘over-registered’ or ‘ghost’ patients. We conducted this analysis at several different area levels (eg: region, CCG) and used statistical techniques to investigate the relationship between levels of registration and deprivation, urbanicty, ethnicity, age, sex and mean distance to practice.

Our analysis showed that levels of ghost patients did vary considerably throughout the country. However, we picked up on several significant factors associated with higher levels. The most significant driver was an increased proportion of non-white population. Other significant factors were increased levels of deprivation and higher proportions of female or elderly patients.

The drivers for ‘ghost patients’ are complex, not fully understood and have nothing to do with fraud

Patients who remain on a practice list but no longer live in the UK will account for some of the over-registration. There are an estimated 4.5 to 5.5 million Britons living abroad. Unless a person leaving the UK specifically informs their GP or hands in their NHS health card, they would not normally be removed from the GP register. I worked in Australia for a couple of years, but remained registered with a UK GP. Had an analysis of my GPs list taken place whilst I was away, I would have been a ghost patient. Non-white populations in the UK tend to be more transient and more likely to move abroad. They are also likely to have larger numbers of foreign residents who would not feature on the census but would be eligible for GP registration. It is also not unusual for practices to treat British ex-patriots temporarily returning home to use NHS GP services.

We know that, despite nationwide over-registration, there are people, entitled to NHS care in the UK, who are not registered with a GP. If a group of male and female immigrants move to the UK for the first time, the men of the group may be less likely to register with a GP because of their lesser use of healthcare than the women. This hypothesised under-registration of men, on the background of widespread over-registration, could account for the increased likelihood of over-registration in populations with higher proportions of women. Elderly populations also consult more and this could explain why there are higher rates of over-registration in populations with larger percentages of patients aged 60 or over.

In short, there are drivers for ‘ghost patients’. They are complex, not fully understood and have nothing to do with fraud.

Dr Patrick Burch is a GP in Manchester and National Institute for Health Research In-Practice Fellow at the Centre for Primary Care, Institute of Population Health, University of Manchester