Choice of GP practice - Guidance for PCTs

Below is copied text from the DH document released in January 2012 describing the arrangements PCT must have in place by April 2012 to deal with the new outer boundaries for GP practices when patients move just out of GP area but can stay registered and the arrangements for home visiting of those patients who are in the pilot of boundary less practices. It also describes new arrangements to simplify the legislation around open and closed lists.

26 January 2012

1. Introduction

1.1. This guidance sets out:

the action that all PCT clusters need to take by 1 April 2012 to ensure that patients who register with a GP practice away from home (“out of area patients”), as part of the forthcoming GP choice pilots in 2012/13, are able to receive home visits where necessary and have access to other urgent care services (section 3);
the action needed to ensure effective and efficient arrangements for access to community health services for out of area patients (section 4);
the action needed to establish outer practice boundary areas for all GP practices, so that people who move home within these areas can stay registered with their current GP practice if they wish (section 5);
arrangements to clarify and simplify the system of open and closed lists (section 6); and
best practice on providing information to support informed choice of GP practice (section 7).

2. GP choice pilots

2.1. NHS Employers (on behalf of the Department of Health) and the BMA General Practitioners’ Committee have agreed that, during 2012/13, there will be a pilot programme to test and evaluate two different models for giving people greater choice of GP practice.

2.2. We have selected three pilot areas, on the basis that they are in cities or parts of cities where there is a significant influx of people on a daily basis. Some are in a NHS 111 pilot area. The pilot areas will be:

Central London: Westminster, City & Hackney and Tower Hamlets
Manchester and Salford
Nottingham City.

2.3. Under the pilot arrangements, people who live outside the practice area will be able to either:

register with a participating GP practice as an out of area patient (in which case they would cease to be registered with their current GP practice) Sections 3 and 4 below will apply to this category of patient; or
have a consultation at a participating GP practice as a nonregistered ‘day’ patient (in which case they would remain registered with their existing GP practice).

2.4. GP practices in these areas will be able to join the pilot on a voluntary basis.

2.5. The pilots will run for one year from April 2012 (subject to legislation) and will be subject to evaluation.

Full details of the scheme can be found here

3. Urgent care (including home visits) for out-of-area registered patients

3.1. All PCT clusters will need to ensure that anyone living in their area who registers as an ‘out-of-area’ patient with a GP practice in the choice pilots has clear information about:

how best to access local urgent care services if they are unable to go to their GP practice (but a home visit is not clinically necessary)
who to contact if they need a home visit during the ‘in-hours’ period
arrangements for accessing out-of-hours services (as now)

3.2. Where someone chooses to register as an out-of-area patient with a participating GP practice in one of the pilot areas, the practice will not be required to provide home visits.

3.3. The PCT cluster where the out-of-area patient lives will be responsible for ensuring that there are alternative arrangements in place. Such a patient who falls ill at home during the ‘in-hours’ period (8.00am to 6.30pm, Monday to Friday), or who is recovering at home after a period of hospitalisation, should be able to access urgent care or receive a home visit where clinically necessary. This will be in addition to the PCT cluster’s existing responsibility for ensuring access to out-of-hours services, including home visits.

3.4. We anticipate that people who choose to register further away from home under the pilot arrangements will typically be working-age adults without complex health problems, who are less likely to require home visits. The NHS nonetheless has a clear duty of care to people who fall ill at home and need urgent care or need home visits following a period of hospitalisation. All PCT clusters will need to ensure they have arrangements in place to meet these needs.

3.5. PCT clusters are reminded of the requirement for a coherent 24/7 urgent care service to be in place in every area of England by April 2013. Some PCT clusters will already have 24/7 urgent care arrangements that can provide home visits. In other cases, PCT clusters will need to put in place other arrangements for 2012/13 to meet the needs of any patients who register away from home as part of the pilot scheme.

3.6. These arrangements could include services provided by

the GP practice with which a patient was previously registered, or with other GP practices in the area
groups of GP practices (possibly building on examples of existing collaborative arrangements for home visiting)
a GP-led health centre, walk-in centre or urgent care centre
an out-of-hours service (if, for instance, it is already extending its activities into the in-hours period)
ambulance services.

3.7. Where a patient registers as an out-of-area patient with a practice participating in the pilot, the ‘home’ PCT cluster will need to ensure that the patient has clear information about how they can access local urgent care services if they have an illness or injury and are unable to see their GP practice. PCT clusters will also need to ensure that NHS Direct and NHS Choices hold up-to-date information. As the NHS 111 service is rolled out, this will enable patients to call a single number to ensure they access the most appropriate urgent care service.

3.8. The Department will share examples of good practice in arranging access to home visits.

3.9. PCT clusters will need to ensure that arrangements for urgent care, including any necessary home visits, are in place by 1 April 2012.

4. Co-ordination with community-based services

4.1. GP practices are the main coordinator of NHS services for patients, where appropriate referring or signposting people to other services within the community, such as health and wellbeing services, services for children, young people and families, services for acute care closer to home, services for people with long term conditions, and rehabilitation services.

4.2. All PCT clusters will need to be prepared for the possibility that patients who register away from home may on occasion need to use these local community-based services. For example, someone registered away from home might have an operation and require a package of care from the district nursing service, or a pregnant woman or new mother may need to use maternity services near their home if they have registered with a practice further away.

4.3. Where patients are registered away from home under the pilot arrangements and require access to such services, the GP practice where the patient is registered will need to discuss with the patient whether it is better for them to:

use the community health teams attached to the practice; or
be referred to community services that cover the area in which they live.

4.4. Around two-thirds of respondents to the Department’s 2010 consultation on opening up GP choice said that they would prefer to use community-based services near their home, whereas a third of respondents said that they would be more likely to use services attached to the practice.

4.5. During the pilot period, it will be essential that PCT clusters, community health services and GP practices work collaboratively to develop efficient and effective arrangements for patients in these circumstances, based on the following principles:

the GP practice with which the patient is registered should always remain responsible for discussing the options with the patient and agreeing a course of action
the ‘home’ PCT cluster should ensure that there is readily available information about how to access and refer to community services in their area, so as to streamline the process for both the patient and referring clinician.

5. Practice boundary areas

5.1. Under the agreement between the Department and the BMA, all PCT clusters will need to work with GP practices to establish outer boundary areas so that patients who move home within these areas can stay registered with the practice if they wish.

5.2. The agreement recognises the needs of patients who move home a relatively short distance away and who, under current arrangements, have to re-register with a new practice when they would prefer to stay with their existing practice with whom they may have a well established relationship. This builds on existing examples of GP practices that allow patients who move outside the normal catchment area to stay registered.

5.3. PCTs clusters should discuss with each GP practice an appropriate outer boundary area. Practices will then be expected to allow registered patients who move home within this area to remain registered with the practice, unless it would not be in the patient’s interests to do so.

5.4. Where a GP practice already has a reasonably large boundary area, it may not be appropriate to establish an additional outer boundary area, although it is expected that this will be the exception rather than the norm. PCT clusters should work with GP practices to ensure that the arrangements are as fair and equitable as possible and that they serve patients’ interests.

5.5. Where outer boundary areas have been agreed, and contracts amended, practices will need to set these out in their practice leaflets and on their websites. This information should also be made available on the NHS Choices website.

5.6. Where a patient lives within the outer boundary area of a GP practice, that practice would, as now, have continuing responsibility for home visits. Where patients rely on frequent home visits from their GP practice, it is in their interests to choose a practice within a reasonable travelling distance of where they live to ensure that it is able to provide these visits.

5.7. Whilst agreeing outer boundary areas, PCT clusters may wish to take the opportunity to work with GP practices to review any existing (inner) boundary areas with a view to improving equity for patients and for practices. In some areas, there is significant and unwarranted variation in the size of practice catchment areas, even allowing for differences in travel time. Some PCTs and GP practices have in the past agreed changes to practice boundaries to ensure, for instance, that patients across the PCT have a choice of at least three or four practices.

5.8. PCTs clusters have access to a variety of different IT systems and software, usually based on Geographic Information Systems that allow them to identify and map the location of practices and their surrounding catchment area. The NHS Information Centre’s Digital Mapping Data framework agreement enables any NHS organisation to call off from a menu the specific mapping data with the appropriate level of coverage that meets their requirements. This is available at:
www.ic.nhs.uk/statistics-and-data-collections/population-andgeography/digital-mapping.

6. Open and closed lists

6.1. We intend to make the system of practice lists more transparent for patients, so that they can be clear whether or not a list is open or closed to new registrations.

6.2. A practice’s list of patients must be either open or closed.

6.3. An open list means that a practice is able to accept applications to join its list. A practice with an open list can refuse an application only where it has reasonable, non-discriminatory grounds for doing so.

6.4. When a list is closed, a practice may only accept applications to join its list from immediate family members of its registered patients. Practices have to gain approval from their PCT to achieve this status.

6.5. Under the current arrangements, practices may have to give up providing additional or enhanced services in order to close their list. This has led to some practices declaring their list “open but full”. This is not a legally recognised term within the contractual arrangements, and it is confusing for patients.

6.6. PCTs currently agree a time period of up to 12 months for a practice’s list to remain closed, but with a default of 12 months in the absence of an agreed shorter period.

6.7. From 2012/13, we intend to introduce legislation which will simplify the processes so that there are no incentives for practices to seek to declare “open but full” lists and so that there is a shorter default period for a closed list. Under the new arrangements, our proposals include:

the new list closure procedure to start with a practice making a written submission to their PCT setting out the reasons for seeking to close their list: this will be a new requirement, replacing and expanding on the current ‘closure notice’;
the restriction on a practice’s ability to withdraw its application to be removed;
the discretionary discussions with the practice in stage 2 to become mandatory (currently a mandatory discussion must take place at stage 1, with further discretionary discussions at stage 2);
when determining a practice’s application, the PCT to be required to consider explicitly the effect of the list closure on patients;
the practice to have more say over the closure period and to be able to re-open the list when it wishes, subject to a notice period;
there will no longer be provisions that allow lists to re-open and close according to rises and falls in list sizes (the so-called “pingpong” arrangements); the assessment panel procedure to be abolished; and a practice with a closed list to retain its right to deliver additional and enhanced services, and any proposal for withdrawal from such services to follow the normal contractual rules.

7. Information: supporting patients’ choice of GP practice

7.1. It is crucial that the public have access to a wide range of reliable and user-friendly information so that they are empowered to make the choice that is right for them, including:

explanations of what choices they can make and when;
the range of services available at different GP practices; and
information about quality of services, including patient experience.

7.2. The NHS Choices website includes practice profiles and enables people to compare, and rate and comment on, the services provided by GP practices. However, this information is not always updated by practices and not all have complete profiles on the main NHS Choices website. PCT clusters will also need to ensure that GP practices’ websites are up to date.

7.3. To help people make the right decision about their choice of GP practice it will be important that they can readily access information such as:

opening times
the practice’s inner and outer boundaries
whether the practice is accepting new patient registrations, i.e. it has an open list
details of any additional services or clinics that the practice provides

7.4. All practices should also have practice leaflets that set out relevant information for patients.

7.5. PCTs clusters will want to work with practices to ensure that:

they have accurate, up-to-date profiles on NHS Choices
they have up-to-date practice leaflets
details of outer practice boundaries, once agreed, are included on NHS Choices and in practice leaflets.

7.6. PCT clusters will also wish to work with Local HealthWatch organisations, as they evolve from the current Local Involvement Networks (LINks), so that they are well placed to provide information to assist people in making choices about GP services.