GPC Guidance on List Closures
The following guidance is based on information contained in ‘Quality first: Managing workload to deliver safe patient care’, available on the BMA website at:
Formal list closure
GMS and PMS practices can apply formally to close the practice list if their workload is jeopardising their ability to provide safe care for their registered patients. This is permitted by The National Health Service (General Medical Services Contracts) Regulations 2004, which can be accessed here.
Practices that do not wish to have patients assigned to their list by the area team must go through the list closure procedures set out in the regulations (paragraphs 29-31 of Part 2 of Schedule 6). If the area team or the assessment panel approves the closure notice, the contractor’s list is officially closed to assignments. The closure period will be either for a maximum of 12 months, or if a range was specified in the closure notice, until an earlier point in time when the number of patients falls below the bottom figure of the range.
The GPC has worked to ensure that the closed list arrangements are less punitive than in the past and practices that do undertake a formal list closure are not faced with any sanction by the area team, such as the threat of removing enhanced services.
However, you should note that formal list closure requires area team consent and the following should be taken into account:
Instead of list closure, is there an opportunity to negotiate with the area team for staffing support with other services?
There will be a responsibility on both the practice, the Area Team/LHB (Local Health Board) and the CCG to ensure that all options other than closure have been considered.
Document what options you have considered in trying to address the problems being faced and the outcomes of those considerations.
Discuss your individual practice problems at the earliest opportunity with your LMC who will provide you with confidential help and support in line with the rules and regulations
Consider the possible impact on neighbouring practices and any help they can provide.
Meet neighbouring practices including LMC representation to discuss the problems that the practice is facing.
Request a meeting with the Area Team/LHB and let them know you will be accompanied by a LMC representative.
Discuss with your patient liaison group to explain how and why you have come to this decision and to listen to any suggestions they may have to ease the pressures.
Informal list measures
Key points to consider
In addition to the formal list closure procedure all practices have the contractual right to decline to register any new patients without having to go through the formal processes and without needing to obtain area team permission. However the formal closure route makes it far more difficult for the area team to be able to allocate any new patients to the practice list.
A practice can decide not to register new patients, provided it has ‘reasonable and non-discriminatory grounds for doing so’, (such as protecting the quality of patient services.) In such cases, the regulations allow practice to refuse to register new patients (paragraph 17 of Part 2 of Schedule 6).
A practice cannot pick and choose which patients it declines to register in these circumstances e.g. refusing nursing home or care home residents, as that would clearly be discriminatory and breach the contractual regulations. The only exceptions which could be reasonably argued would be new babies of registered mothers and perhaps other first degree relatives in the same household if it could be demonstrated that it would be in the patients’ best interests to be registered with the same practice.
Should a practice be unable to accept patients routinely, a discussion between the practice and the area team could take place in an attempt to resolve the situation. This could involve, for example, additional support being provided by the area team and would normally lead to an application for formal closure.
The contractor does not need to make an official declaration of its intention to refuse to register new patients. However, the regulations state they must provide the patient with a written notice. In addition it is good practice to put up notices, provide patient leaflets and post on its website that it is temporarily unable to accept any new registrations, and explain the reasons why.
The area team may still assign patients to the contractor’s list (paragraph 32 of Part 2 of Schedule 6) as its list is open to assignments within the meaning of the Regulations. Practices should bear in mind that the area team may ask them to justify the decision not to register a patient. Practices must ensure that their actions do not discriminate between patients on the grounds of the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition. A written acceptance policy will enable practices to refute any suggestion of improper rejection of applications. There are equivalent procedures in the regulations for the devolved nations.
Practices should not refer to their list as ‘closed’ when it has not been formally closed and should state only that they have concluded that they cannot at present take on further patients.
If the practice is unable to take on additional patients on the basis of safety/quality of care then the practice should enter into discussions with their area team and LMC leading to an application for formal list closure.
NHS England view
NHS England has stated the following regarding list closures:
“Patient safety is the top most priority. Both for commissioner and provider, commissioning services need to always reflect that and the contract is a means by which we can ensure that a practice is continuing to offer safe and high quality services to patients.
For a practice to formally close its list, we require it to consult with patients and other key local stakeholders. Clearly, NHS England has a responsibility to ensure that services are available to patients. There are different issues raised if an urban practice closes its list compared to one that supports a very rural and large practice area, so all cases will be considered on a case by case basis.
If a practice is experiencing severe disruption, then of course it may be necessary to take immediate action, so that the practice can maintain safe services. However, a provider should be communicating with the commissioner as soon as practical in order to establish a plan of action to address the issue.
If the issues are not imminently likely to be rectified, then in order to fully assess the impact of a closed list on local services for patients, a formal request to close a list should be made, so that the views of patients as well as local GP and community pharmacy services can be taken into account. In most circumstances, we find that patient groups and local health services are very understanding of a practice difficulties, however practices don’t exist in isolation, and we need to ensure that a closed list does not adversely affect the pressures being experienced elsewhere, in another practice.
Because of our need to ensure we engage with the local community regarding the services we commission, we do not accept that a practice can close its list without going through a formal process of engagement. However, we do appreciate that there are times when urgent action needs to be taken. If there is a sudden impact on a practice’s ability to provide patient services, we accept that a temporary halt to new patient registration is appropriate, but this should be followed quickly by a discussion with the commissioner to identify an action plan to address the issues. Where it is evident that the issues can be resolved within a short time scale, then we would look to support a practice address these issues without requiring formal list closure.
If progress was not being made, we would advise that consideration be given formally to close the list.
Where a practice is opting to restrict patient registration without discussing the implications and appropriate actions with NHS England, we would consider whether contractual action ought to be taken.”
In addition to the above, the Central Midlands Sub-Regional Team of NHS England has provided the following:
“From a local perspective, we would always urge a GP practice experiencing difficulties to contact their local NHS England Contract Manager at an early stage. GP practices experiencing difficulties often consider working more closely with neighbouring practices, including exploring options for mergers and federations. At a local level, NHS England can support these discussions and encourage practices to fully engage with their CCG, which may also be able to offer support.
Unmanaged list closures have the potential to be problematic for patients and other local practices; for example, in rural areas where only one or two practices may cover a given location, patient access to a GP could become unduly restricted. The formal list closure process allows local commissioners scope to engage with neighbouring practices and to assess the impact that a closed list may have on other practices in a locality.”
NHS England has agreed to meet with GPC shortly to discuss the above.