Patient Registration - List Capping

In January 2015, the GPC’s ‘Quality First: Managing Workload’ document included, under Part 8 ‘List Management’ a reference to the ability of GP practices to decline to register new patients if by doing so this would protect the quality of patient services for those already registered at the practice.  Over the past year it is clear that the demands on GP colleagues have continued to increase, both in terms of workload but also capacity, which make maintaining the quality and safety of General Practice services more challenging.

As colleagues will be aware, any practice can apply, under Paragraph 29 of Schedule 6, Part 2 of the NHS (GMS Contracts) Regulations (as amended) to close their list.  PMS Contracts outline a similar process.  NHS England or (for those practices where their CCG has taken on delegated (level III) co-commissioning responsibilities) the CCG has an application form to complete for practices wishing to apply to close their lists.  As part of this process, NHS England (or the CCG) will request the views of local practices and the CCG, which in the case of delegated CCGs will require a novel approach, in terms of the practice’s application.  The practice will be asked to explain why it is requesting list closure, and what steps it has taken to avoid this.  It is important to note that the final decision, permitting a practice to close its list, or denying the application, is made by NHS England (or the CCG). Practices do not have control over the outcome of this decision, although it is possible to appeal it.  If agreed the list can be closed for up to twelve months.

Capping the practice list is a decision made by the practice, based on the quality and safety of services that can be delivered to patients.  In 2015 the LMC attempted to agree guidance with NHS England (Surrey and Sussex) in terms of how this process would operate.  Further guidance was also expected from NHS England, but this has not become available.  It was not possible to achieve a jointly agreed approach, but NHS England is aware of the guidance being sent by the LMC to all practices.  The LMC recommends that all practices inform NHS England if they plan to cap their list.

Practices should also note that when their lists are formally closed, under Regulation 33, it is very difficult for patients to be allocated.  If a practice caps their list, the allocation process is unaffected.

Practices can continue to provide current DES, Locally Commissioned (Enhanced) Services, and Public Health Commissioned Services, whilst their lists are closed or capped and there is no provision within the Regulations that precludes a practice from continuing to deliver such services in such circumstances, or undertaking newly commissioned services.

Practices should be aware that NHS England believes that, should a practice wish to stop accepting new patients, the practice should apply to close their list.  There is no requirement within the Regulations for practices that decide to cap their list to concurrently, or after a short period of time, apply to close their list under Paragraph 29.  The LMC recommends that practices see the two processes as distinct and only apply to close their list if they wish to do so. 

If practices do cap their lists and therefore decline to register all new patients, there are certain regulations that apply;  in particular, practices must inform applicants for registration in writing of the reason for declining to register and keep a record of this,  and these records must be made available to NHS England (or a delegated CCG) on request. The applicable Regulations are listed in Appendix 1:

 

APPENDIX 1

Refusal of applications for inclusion in the list of patients or for acceptance as a temporary resident

17     (1)  The contractor shall only refuse an application made under paragraph 15 or 16 if it has reasonable grounds for doing so which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.

(2) The reasonable grounds referred to in paragraph (1) shall, in the case of applications made under paragraph 15, include the ground that the applicant does not live in the contractor’s practice area.

(3) A contractor which refuses an application made under paragraph 15 or 16 shall, within 14 days of its decision, notify the applicant (or, in the case of a child or incapable adult, the person making the application on their behalf) in writing of the refusal and the reason for it.

(4) The contractor shall keep a written record of refusals of applications made under paragraph 15 and of the reasons for them and shall make this record available to the Primary Care Trust on request.

The LMC has also sought in the following guidance to minimise the disruption that may be caused to patients by list capping and recommends practices agree, and follow, a clear practice policy when implementing this decision.  It may well be that practices can anticipate reason(s) for needing to cap their list will be temporary, and so will do so for a fixed period of time.  Some practices may feel this approach is needed for an indefinite period.  Clearly there are other practices who wish to increase their list size and will be pleased to do so.

The LMC will support any practice that, for appropriate reasons, wishes to cap (or close) their list and if practices have any queries please do not hesitate to contact the LMC Office.

LMC Recommendations: List Capping Process

The practice should consider not registering new patients, if continuing to do so would jeopardise their ability to provide safe care to those patients already registered at the practice.

The practice should consider if this is currently the case, or if they could anticipate reaching a ceiling list size number in the near future, based on the rate of current registration/re-registration requests.

In either case practices should contact their NHS England contract manager to inform them of this decision, and, in the case of a planned ceiling, inform NHS England when they anticipate reaching this, as far as this is possible to predict.

Practices are also recommended to inform the CCG, and should do so directly if their CCG holds delegated (Level III) co-commissioning status.

When informing the Area Team and CCGs, the practice should ask if there is any support either organisation could offer the practice of a nature which would make it unnecessary to cease registering new patients and consider whether such support means it is unnecessary to cap the list.

By capping their list, the practice is declining to register all new NHS patients for the time being.  Practices should do so in a non-discriminatory way, and therefore should not discriminate between patients who reside within or outside the practice boundary, or who are, or are not, currently registered with any practice locally, or indeed any other practice.  However, the LMC would be of the view that it would be appropriate and not discriminatory to continue to register:

• newborn or adopted babies of parents already registered at the practice
• first degree relatives of patients already registered at the practice who are living or will be living at the same home address

Practices should inform patients that the practice is not currently registering new patients via notices in the practices and on the practice website.

Patients who request registration and are declined are entitled to a letter from the practice explaining why their registration has not been accepted [suggested template].

Practices must also keep a list of patients who have been declined registration and NHS England or the CCG are entitled to request this list.

Practices should not keep a ‘waiting list’ of patients to be contacted when the practice is once again accepting patients.

Practices should provide NHS England, on request, with the reason(s) why the decision to cap their list is being made.  Such reasons may include:

• Unexpected demands on practice services, such as a rapid increase in registration requests. 
• Insufficient clinical staff available to provide a safe service, eg: due to unexpected illness, inability to obtain a locum for a planned absence, such as maternity leave, or inability to recruit to a substantive post following retirement or resignation.
• Unexpected or unresolved infrastructure difficulties, such as building damage or IT failure.

There may be other relevant reasons and it is expected the Area Team may require some evidence.

Practices should provide NHS England with some indication of how long they would expect to cap their list; this and the appropriateness of requesting formal list closure will be, the LMC anticipates, of particular interest to NHS England and practices may find it helpful to forward any correspondence from NHS England in relation to these points to the LMC.

Practices who do wish to formally close their list should contact the Area Team and obtain the appropriate application form.

Practices should, ideally, not ‘cap’ and ‘un-cap’ their list repetitively as this will be confusing to patients. The LMC had identified this issue as one that would ideally have agreed timescales with NHS England.  Whilst such a joint agreement has not been reached, the LMC suggest setting a fixed period in which the practice list will be capped and then reviewing this regularly based on the reason(s) justifying the original decision to cap the list.

Practices may anticipate they may receive enquiries from the local media or MPs. It is recommended a pre-prepared response is made available. NHS England or the CCG may also be able to offer assistance in responding to such queries.

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Updated on Thursday, 28 March 2024

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