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The rules on list maintenance

List cleansing exercises are increasingly common to curb 'list inflation', but GP leaders say practice lists are in line with population growth.

PCTs' 'liist cleansing' exercises have been controversial
PCTs' 'liist cleansing' exercises have been controversial

The NHS Commissioning Board will take over list maintenance for practices in England from PCTs when they are abolished next year, but the rules around lists will still change annually. 

In England, the rules on list maintenance are governed by the annual Operating Framework. The 2012/13 version, which was published last November, included tackling list inflation as a new indicator called PHF06.

It states that PCT clusters must ‘work with GP practices to undertake a full review of practice registered patient lists, ensuring patient anomalies are identified and corrected by March 2013’.

List cleansing
List cleansing means PCTs save money by paying practices less global sum. Figures from NHS Primary Care Commissioning (PCC) reveal that NHS South Gloucestershire recently removed 2,274 patients from its lists, saving £146,878 based on GMS pay of £64.59 per patient.

It did this by writing to all 13,250 patients who met the criteria of being registered for more than two years but who had not had a consultation or been prescribed for five years.

But GP leaders claim that last year’s census figures revealed that list deflation, not inflation is happening, as was previously suggested by some PCTs. 

Population growth
GPC deputy chairman, Leeds GP Dr Richard Vautrey says: ‘The census has shown a big growth in population numbers. Previously it was suggested that practice list numbers were artificially inflated. Now it is clear that they are not, and are in fact in line with the actual population.

‘If a practice has concerns about list cleansing they should let their LMC know and the LMC will need to take this up with the PCT. After April this will be the responsibility of the NHS Commissioning Board in England. Now that the census figures have been released, and the evidence suggests that practices lists are in line with census figures, it makes over zealous list cleansing even more unjustified.’

List cleansing exercises have been carried out by PCTs on a regular basis. However PCC warns that list cleansing should only be carried out if the authority knows that a saving is going to be made after the operational costs of the exercise are taken into consideration.

Risk to patients
It also warns that removing patients from GP registered lists is not without risk to patient care as it means patients can be missed from national screening programmes. And they will also cost more money once re-registered as they will register as new patients, thereby increasing their per capita cost.

In February, PCC advised PCTs to train practices to use the FP69 process, which places holding cards in paper records or flags them electronically on the GP system if the practice has had any mail returned from individuals. These patients are then removed if the practice has not heard from them within six months.

But some GPs are warning that in some areas up to 25% residents are not registered with a GP practice. Londonwide LMCs medical secretary Dr Tony Grewal says: ‘The 2011 census figured show that it is list deflation, not list inflation that is happening. In some boroughs 25% of the population are not registered.’

More clarity over list maintenance
Dr Grewal is also calling for more clarity and stability regarding list maintenance. He says: ‘The only requirement for list maintenance is through the Operating Framework and every year a new one comes out.’

Dr Grewal says the latest framework has already overridden the Once for London project, the capital’s set of operating principles for list maintenance, which attempted to stop mass patient removals that financially destabilised some practices.

In April this year, the DH published its Patient Choice guidance which reiterated that ‘practices’ lists of NHS patients must be either "open" or "closed" to new registrations, and this will not change'.

An open list is the default position and means a practice is able to accept applications to join its list. DH guidance says: ‘An open list can only refuse an application where it has reasonable non-discriminatory grounds for doing so.’

For a practice to close its list, it must have consent from the PCT and from next April, the NHS Commissioning Board. A closed list means that a practice can refuse applications to join its list from anyone other than from immediate family members of its registered patients.

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