Guidance on Requirements for Registering with a GP - Standard Operating Principles for Primary Medical Care.
Although there has not been any change in national policy in respect of patient registration for primary medical care services – this guidance clarifies the rights of patients and the responsibilities of providers in registering with a GP practice. The reason for issuing this guidance now is evidence of an increasing number of patients finding it difficult to register with some GP practices. This is because they cannot provide documentation to the practice in support of who they are or where they live and the subsequent problems they have in accessing health care. The guidance is designed to clarify the position for all patients. In particular though, this issue is affecting migrants and asylum seekers who do not have ready access to documents.
Full & further information can be found here: guidance on registering with a GP..
Under the terms of their primary medical services contracts, GP practices cannot refuse an application to join its list of NHS patients on the grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.
Other than that, they can only turn down an application if:
- The commissioner has agreed that they can close their list to new patients,
- the patient lives outside the practice boundary; or
- if they have other reasonable grounds.
In practice, this means that the GP practice’s discretion to refuse a patient is limited.
Assessing Patient ID at Registration
Seeing some form of ID will help to ensure the correct matching of a patient to the NHS central patient registry, to ensure previous medical notes are passed onto the new practice. It is legitimate therefore for the practice to apply a policy to ask for patient ID as part of their registration process.
In such circumstances however, the policy must make clear what action should be taken when a patient is unable to supply any form of ID.
Any practice policy to ask for patient ID should be applied in a non-discriminatory fashion. This means the policy should apply to all prospective patients equally.
A practice policy should not routinely expect a patient to present a photograph as this could be discriminatory.
If a patient cannot produce any supportive documentation but states that they reside within the practice boundary then practices should accept the registration
Homeless patients are entitled to register with a GP using a temporary address which may be a friend's address or a day centre. The practice may also use the practice address to register them if they wish. If possible practices should try to ensure they have a way of contacting the patient if they need to (for example with test results).
The majority of patients will not find it difficult to produce ID / residence documentation. However there will be some patients who do live in the practice area, but are legitimately unable to produce any of the listed documentation. Examples of this may be:
- People fleeing domestic violence staying with friends or family
- People living on a boat, in unstable accommodation or street homeless
- People staying long term with friends but who aren’t receiving bills
- People working in exploitative situations whose employer has taken their documents
- People who have submitted their documents to the Home Office as part of an application
- People trafficked into the country who have had their documents taken on arrival
- Children born in the UK to parents without documentation
Reasonable exceptions therefore need to be considered and the individual registered with sensitivity to their situation. It is important that these people have equitable access to primary care services
As there is no requirement under the regulations to produce identity or residence information, the patient MUST be registered on application unless the practice has reasonable grounds to decline. Registration and appointments should not be withheld because a patient does not have the necessary proof of residence or personal identification. Inability by a patient to provide identification or proof of address would not be considered reasonable grounds to refuse to register a patient.
Who can register for free primary care services?
A patient does not need to be “ordinarily resident” in the country to be eligible for NHS primary medical care –this only applies to secondary (hospital) care. In effect, therefore, anybody in England may register and consult with a GP without charge.
Where a GP refers a patient for secondary services (hospital or other community services) they should do so on clinical grounds alone; eligibility for free care will be assessed by the receiving organisation.
It is important to note that there is no set length of time that a patient must reside in the country in order to become eligible to receive NHS primary medical care services.
Therefore all asylum seekers and refugees, students, people on work visas and those who are homeless, overseas visitors, whether lawfully in the UK or not, are eligible to register with a GP practice even if those visitors are not eligible for secondary care (hospital care) services. The length of time that a patient is intending to reside in an area dictates whether a patient is registered as a temporary or permanent patient. Patients should be offered the option of registering as a temporary resident if they are resident in the practice area for more than 24 hours but less than 3 months.
Refugees and Asylum Seekers registering at your practice
To access more information on how to support migrant patients, please go to https://www.migrant.health/
Immediately necessary treatment
General practices are also under a duty to provide emergency or immediately necessary treatment, where clinically necessary, irrespective of nationality or immigration status. The practice is required to provide 14 days of further cover following provision of immediate and necessary treatment.
As a minimum requirement the arrangements above in respect of the registration of any patient with a GP surgery should be followed when the person registering is a child. However, there are circumstances that practices should be aware of, in relation to safeguarding guidance.
The legal definition of a child is 0 to 18 years of age; however young people may be able to make independent decisions from as young as 12, depending on the circumstances. Section 11 of the Children Act 2004 places a statutory duty on the NHS to safeguard and promote the welfare of children. The Victoria Climbie Enquiry Report 2003 (9.104) stresses the importance of GP registration for every child. It sets out the importance of knowing the identity of those registering the child and their relationship to that child.
If a child under 16 attempts to register alone or with an adult that does not have parental responsibility, the Practice Child Safeguarding Lead should be alerted.
For purposes of safeguarding children, the following should be considered whilst recognising that patients must still be registered in the absence of documentation and policies must be applied in a non- discriminatory manner.
The practice should seek assurance through:
- Proof of identity and address for every child, supported by official documentation such as a birth certificate (this helps to identify children who may have been trafficked or who are privately fostered).
- An adult with parental responsibility should normally be registered at the practice with the child. The ID of the adult is useful as it can be matched to the birth certificate details. However, the practice should not refuse to register a child if there is no-one with parental responsibility who can register, as it is generally safer to register first and then seek advice from the Safeguarding Practice Lead, Health Visitor or Practice Manager. (This situation may alert you to a private fostering arrangement which constitutes a safeguarding concern.)
- Offering each child a new patient registration health check as soon as possible after registration.
- Seeking collaborative information (supported by official documentation) relating to:
- current carers and relationship to the child;
- previous GP registration history;
- whether the child is registered with a school and previous education history;
- previous contact with other professionals such as health visitors and social workers.
- Children who have been temporarily registered with the practice should be reviewed regularly and proceed to permanent registration as soon as possible and ideally within three months of initial registration. Likely length of stay should be determined at initial registration and patient registered as temporary/permanent, as appropriate.
- Children of parents or carers who have been removed from the list for any reason must not be left without access to primary care services.
- Where parents or carers have been removed from the list due to aggressive and/or violent behaviour, a risk assessment should be completed to identify any risk to their children and the appropriate referrals made.
Practices should be alert to potential risks such as those described above when young people aged between 16-18 years of age register alone and dealt with in line with practice safeguarding procedures and escalated outside of the practice through the local procedures if appropriate.
Registration of those previously registered with Defence Medical Services (DMS) and Priority NHS care for Veterans
DMS have their own GP services that look after serving personnel, mobilised reservists and some families. These primary care services are commissioned separately by NHS England. When servicemen and women leave the armed forces, their primary healthcare reverts to the responsibility of the local NHS. As a minimum requirement the arrangements set out above in respect of the registration of any patient with a GP surgery should be followed when the person registering is a veteran. Prior service should be recorded on registration and allocated the correct Read/Snomed Code.
This should enable access to specialist care or charity support as necessary for such patients. A veteran is an ex-service person or reservist who has served in the armed forces for at least one day. There are around 2.5m veterans in England at the time of drafting. All veterans are entitled to priority access to NHS hospital care for any condition as long as it's related to their service (subject to clinical need), regardless of whether or not they receive a war pension.
All people leaving the armed forces are given a summary of their medical records, which they are advised to give to their new GP when they register. The practice will also be advised of prior registration with Defence Medical Services and with a summary of their in-service care. More information on the duty of care owed to service personnel is contained in the armed forces covenant which can be found here; https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/49469/the_armed_forces_covenant.pdf
Persons released from prison and/or in contact with the criminal justice system
As a minimum requirement the arrangements set out above in respect of the registration of any patient with a GP surgery should be followed when the person registering has just been released from prison or young offenders institute and/or is in contact with the criminal justice system. It is important that these patients have equitable access to primary medical care services. This patient group MAY produce a letter from either the Youth Offending Team or Community Rehabilitation Companies (CRC) stating that they have a place to stay, this letter should suffice for registration purposes under the category ‘documentation from a reputable source’ where the practice has a policy of requiring documentation at registration.
Contract changes in 2017/18 mean that people can register with a GP Practice prior to their release from secure residential estates (such as prisons, young offender institutions, immigration removal centres and secure training centres). NHS England have produced a one page flowchart guide to assist practices in this process. If practices have any queries, they can email email@example.com.
If a practice refuses any patient registration then they must record the name, date and reason for the refusal and write to the patient explaining why they have been refused, within a period of 14 days of the refusal. This information should be made available to commissioners on request. Commissioners may ask practices to submit the numbers of registration refusals, age, ethnicity and reasons as part of their quality assurance process. For purposes of clarity – it is not acceptable to refuse to register a patient because they are registered with another local practice.
Most practices currently use a GMS1 form and a new patient health questionnaire when patients request to register. You may not be aware but it is not a requirement for practices to use the GMS1 form and you can choose to design your own that could be incorporated into your new patient health questionnaire. However, all the information that is on the GMS1 form must be included within any new form/questionnaire.
When the GMS1 form was updated in 2017, Matt Bailey from the Primary Care Team at Southampton City CCG has created a really useful flow chart which provides information on what practices need to do. It also provides a list of Read codes that can be entered on to the patients medical record where a declaration has been completed. We have sought advice from the GPC in relation to coding, they have suggested to code “Holds European Health Insurance Card” and these codes are highlighted on the flow chart. Click here to access this.
Wessex LMCs has developed some suggested templates that you may wish to use. These are in a word format so that you can adapt them as needed, just click on the relevant link below to access them:
NHS Protect/Local Counter Fraud has asked that when registering a patient, to include a question on where they were last treated . This has been included within our templates however it is up to the practice whether to use this.
We would like to thank the following practices for sharing their registration forms/questionnaires to help us develop these: University Health Service Practice in Southampton, The Wilton Health Centre, The Wellbridge Practice and The Arnewood Practice.
Application to Close Patient List
Please see the following template for applying to close your practice to new registrations: Application to Close List Template