An explanation (if relevant) that this decision does not apply to other members of the patient’s family may be helpful. Although there may be occasional circumstances when this is justified, particularly if a patient is being removed under Para 21 and they are a parent or carer who can be expected to be present when another relative needs to see a doctor, normally when a patient is removed other members of a family should not be simultaneously removed. They may be entirely unaware of their family member’s behaviour, or, in the case of children, not in a position to influence it. En bloc removal of patients who have not been warned of such a risk or who have not engaged in actions that may justify removal can create particularly adverse publicity (if, for example, the local MP or the Ombudsman is contacted) and a complaint which may prove difficult to justify.
This is a common scenario and can be a source of significant discontent. If a practice knows that a patient is residing abroad for a period of longer than 3 months, they can request deregistration on this ground. Practices are not required to do so, but PCSE is obliged to process this removal if it becomes aware of a patient’s absence outside the UK for over 3 months. Coupled to the issue is the patient reregistration with a practice on return to the UK; it may be, for example that such deregistered patients are not eligible to reregister with the practice from which they were deregistered, for example, if they live outside a patients practice boundary and the practice has a policy of not registering patients who live outside their boundary, but not removing patients who historically live there.
Clearly if patients are recurrently absence from the UK for periods of greater than three months on an annual basis, recurrent deregistration and registration are administratively time consuming but this would follow the Regulations.
Just because a patient is maintaining residency for tax purposes, or has UK citizenship, or has paid UK Tax or National Insurance in the past, does not entitle a patient to automatically maintain NHS registration with a UK General Practitioner. NHS primary care services are only available in the UK, although during the pandemic CNSGP Indemnity covered the delivery of remote services to patients stranded abroad because of travel restrictions.
General Practitioners should be particularly cautious about prescribing for patients who are abroad, and not prescribing for longer periods of time than are required for appropriate monitoring or follow-up in relation either to the medication that is being prescribed or the clinical condition that is being treated.
Under Regulations introduced several years ago, practices are entitled [but are not required] to have an inner and outer boundary. If a practice maintains this, then patients who live within the ‘inner’ boundary and move (what is therefore usually a short distance) to live within the ‘outer’ boundary are entitled to remain registered with the practices.
Patients who move outside a practice’s outer boundary and who are currently registered with a practice, or who move outside the inner and outer boundaries, are not entitled to stay with a practice, although this depends on the practice’s policy. If practices are accepting patients’ registrations from outside their inner boundary, patients can register, this would include patients who live within or newly move to within the practice’s outer boundary.
Also introduced some years ago, practices are entitled to maintain an ‘Out-of-Area’ registration for patients outside their inner boundary, whereby practices are not required to undertake Home Visits. OOHs service delivery is unaffected as the patient is treated as registered with the practice.
The LMC does not recommend practices maintain Out-of-Area registration status for patients because there is no uniform in-hours Home Visiting service available to provide this care to patients. This means that if, as they are entitled to do, patients contact the practice for clinical advice, and that advice is that a Home Visit is clinically appropriate, there is no service available for the practice clinician to request to provide this care. This creates a professional dilemma which transcends the contractual position.
In addition, GP practices cannot convert a currently registered patient to an ‘Out-of-Area’ registration: only patients who are not registered with the practice can be newly registered under the ‘Out-of-Area’ registration.
A change in the Regulations in 2020/21 means that patients who have been transferred to the Special Allocation Scheme and are now deemed able to be appropriately reintegrated into General Practice by coming off the Scheme, cannot be reviewed or refused registration.
Practices are still able to deregister or refuse to register patients who are known to have been violent at other GP practices but who have not been placed on and then removed from the Scheme; the point being that the Special Allocation Scheme is supposedly designed not just to provide a continuing primary care service but a rehabilitation service. However, the LMC recommends that practices ask the Scheme or ICB for written evidence that a risk assessment has been undertaken that documents the claim that will be made that a patient is can now be appropriately registered with “normal” General Practice. Simply coming to the end of a fixed period of time on the Scheme does not constitute such evidence, and without it Practices may state they remain at risk.
It is important in any communication with patients to remain entirely factual and polite.
You will find the standard operating primcipals for GP patient registrations within the Primary medical services policy and guidance manual (PGM) which includes processes for managing patien behaviours, and patient removal at the request of the contractor.