Advice on out of area registration v2

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Advice on out of area registration v2
Advice On....
Out-of-Area Registration
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Cambridgeshire LMC
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Out-of-Area Registration,
also called
Choice of GP practice
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We have received numerous questions about both the new contractual arrangements for
out of area patient registrations from 5th January 2015 and the enhanced service that is
currently on offer from the Area Team."
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We thought it would be helpful to try and encapsulate the main issues being raised to help
you understand your new choices and decide on whether to take up the enhanced service."
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There are two different aspects of the change - a new voluntary contractual freedom, and
an optional enhanced service."
THREE things to remember!
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Your first obligation is to provide a safe service to your registered patients, and your
choices must be made with that in mind."
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You have a new freedom to register patients who live outside your area, without any
obligation to visit them, though with some other new contractual requirements. You are
however, under no obligation to do so, and may refuse to register any individual new
patient to your list because they live outside your area."
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The enhanced service, that offers new obligations to consult and visit patients who are
not your registered patients, is entirely optional."
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The LMC hopes this guidance will help you make your choices.
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Contractual issues!
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From 5th January, you will be able to register patients who live outside your practice area
with no obligation to provide home visits. You are not obliged to do so."
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So when a patient who lives outside your practice area asks to register with you, you need
to decide between the following 3 options:"
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1."
Not register the patient. The ability for GP practices to refuse registration on the
grounds that the patient lives outside the practice area remains unchanged. You must
have clinical or practical reasons for not registering the patient - these can relate to how
the practice needs to look after in-area patients, as well as applicant specific factors. We
answer some questions in the FAQs. The LMC would remind you that this has always
been the default option for practices, and remains a valid choice practices may make."
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2."
Register as any other registered NHS patient. We suggest you use caution in
registering new patients who live outside your area, as you have chosen your area to
protect your service and your registered patients, and the obligation to visit out of area can
put other patients at risk."
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3."
Register the patient as an out-of-area registered patient with no obligation to
provide home visits. This assumes you are satisfied it is clinically appropriate and
practical to register the patient in this way. There are some obligations, risks, and things
the LMC would suggest you consider - read on."
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Each patient who requests registration as an out of area patient should be considered
under a practice policy, and we advise you therefore to draw up a policy that is easy to
apply."
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Practices may consider indicating their policy on accepting (or not accepting) patients who
live out of area in their local communications e.g. GP practice/NHS Choices website,
practice leaflet, posters in the waiting room."
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As you can imagine, there are pros and cons to accepting an out of area patient (and
we’re afraid we have listed more cons than pros)"
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Pros:!
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It will generate income for the practice. As always, each newly registered patient will
attract a capitation fee, starting in the quarter after the one in which they register."
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It will enable you to provide continuity to patients who move outside your practice
inner boundary (albeit fragmented care if they fall ill in their new area) - though this is not a
new freedom as you have an outer boundary just for this purpose."
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Cons:!
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The GPC believes that it would be inappropriate to register an out-of-area patient
unless you have definite evidence that the patient’s home Area Team has secured
appropriate services for treating the patient in his/her home area if necessary. "
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Even if you have received adequate reassurances prospectively you will remain
accountable for monitoring and ensuring the quality of all care received by all your patients
during core hours. This will become especially important when the named doctor obligation
for all patients comes into force on 1st April 2015. "
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Your referral pathways for an out-of-area patient may not be obvious or familiar to
you, for the patient may need secondary or community care at home. Any costs generated
by such patients if you decide that they need to be seen in their home area will be charged
to our CCG."
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When choosing to accept an out of area patient, you must not discriminate on
protected criteria under the terms of the Equality Act 2010 - so again the simpler the policy
the better."
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Newly registered patients inevitably generate extra work. Your list turnover could
increase. These patients, by definition, are mobile. Some may not stay for the 3 months
required to generate the first capitation fee."
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NHS England has reserved the right to reduce the capitation fee for out-of-area
registered (OoAR) patients at any time in the future. We have no indication yet as to
whether if that happened and you determined that OoAR patients were no longer
economic, you would have the right to remove OoAR patients from your list on those
grounds. Even if you had that right (and, again, the regulations are silent on the matter) we
do not know how the Ombudsman and the GMC would react – we do know that both
bodies sometimes appear to regard removal of patients from your list as close to a mortal
sin, despite the fact that the standard regulations do give you the right to remove patients
under certain circumstances."
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The OoARS guidance from NHS England states that ‘urgent care’ is where the
patients’ medical condition is such that, in the reasonable opinion of the patient’s
registered practice, attendance of the patient is required and it would be clinically
inappropriate for the patient to go to their registered practice. "
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Clearly, the question of what constitutes ‘clinically inappropriate’ reasons for going to the
registered practice if it is many miles distant from the patient’s home provides even more
fertile grounds for patient complaints than if the practice is close at hand."
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Remember !
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A simple policy, for example one that says
you will accept no out of area patients,
because of practical or clinical needs of
your in area patients, is easy to apply to
each request.
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The enhanced service
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You will have received an email from the Area Team on 1/12/14 regarding the Out of Area
Registration Enhanced Service, with a deadline for responses of 20/12/14."
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If you sign up to the enhanced service, you will need to agree with the Area Team an area
for which you will be responsible. You will then provide urgent Essential Services to any
patients:"
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living within that area who have registered with a practice outside that area who are
unable to attend their registered practice and "
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who that registered practice has deemed to be in need of urgent Essential Services."
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As with the contractual changes, there are pros and cons to signing up for the Enhanced
Service to provide services to OoAR patients residing in your area."
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Pros!
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It will generate income for the practice. The rates are set out in the Enhanced
Service. Only you can decide if they are economic. We do not know whether or how they
will be uplifted in the future."
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Cons!
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The workload will be unpredictable but it will always fall under the heading of
‘unscheduled’. It could mean that you need to make adjustments to the way in which you
commit practice resources (mainly workforce) between routine and urgent care."
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You will not have access to the patient’s full record."
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When a patient contacts you for this service his/her registered practice (and
probably also the 111 service) will already have informed him/her that there is a need for
urgent Essential Services in his/her home area. You may disagree. Clearly, there is
potential here for patient complaints."
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The AT must commission services for the whole of the county. Because not every
practice will take up the enhanced service, there will be geographical gaps. We therefore
anticipate that those practices that do choose to sign up to the enhanced service would be
asked to cover a larger area than their own practice area and we would expect the funding
to increase to reflect any such agreement."
Remember !
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You have a free choice as to whether or not
you sign up to accept the obligations of the
enhanced service."
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This choice is separate from your policy
over accepting out of area registrations.
FAQs!
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Here are some of the questions that have been raised so far along with some that have
been raised nationally:"
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Q: Can we pick and choose who we accept as an out of area patient?!
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A: If a patient living outside of your area asks to register with your practice and you have
an open list, you have to consider their application in line with your policy about out of area
registrations. You may consider clinical or practical reasons."
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Q: What do they mean by clinical or practical reasons?!
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A: Clinical or practical reasons may relate to the specific patient who is applying, or for the
practice as a whole."
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You may decide that not doing home visits would compromise the patient’s clinical care,
and therefore their needs would be better met by registering with a practice near to where
they live. "
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As far as practical considerations go, if the patient does not spend frequent periods of time
in your area such as working regularly in your area, you may decide that it is not practical
for them to register with you and their needs would be better served by registering with a
practice nearer where they live. "
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Q: If we refuse to register a patient because we believe there are genuine clinical or
practical reasons not to do so, can the patient appeal?!
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A: No."
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Q: Could clinical or practical reasons for not keeping a patient on our list emerge
later? Could we legitimately ask them to register elsewhere at a later stage?!
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A: Yes. If your out of area patient develops a condition which means it is no longer
clinically appropriate or practical for them to be registered away from their home, then you
can ask that they consider registering with a practice closer to where they live. It makes
sense to try to explain this issue to out of area patients at the time they register. The rules
over removal in these circumstances are, as yet, unclear."
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Q: If a patient leaves our list to register with a practice near where they work (which
is outside of our boundary) and they subsequently change their mind, are we
obliged to re-register them?!
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A: The normal rules would apply i.e. if you have an open list and they still live within your
boundary, you can only refuse if you have non discriminatory reasons for doing so. "
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Q: What about existing patients who live outside our boundary. Do the new rules
mean that we no longer have to do home visits for them?!
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A: No. This has been quite a common question. The new rules only apply to patients
registered as out of area patients, so if you currently have a patient on your list who lives
outside of your boundary, then you are still expected to provide home visits for them. "
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Q: What if an existing patient moves outside of our boundary? What are our choices
then?!
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A: If the patient moves outside your area and wishes to remain on your list, then as before,
you have the discretion to keep them on your list and provide their home visits. "
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However, if you are happy to keep them on your list but do not wish to provide the home
visits, then you have to remove them from your list and re-register them as a new out-ofarea patient. Then the new rules would apply. "
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Make sure you are clear to the patient what this means and explain that they may be
better served by registering with a practice nearer to their new home. "
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Q: What about students? Can students be registered by university practices now as
out of area patients without home visits?!
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A: No. Students will continue to be treated as registered NHS patients."
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Q: Can students remain registered with their ‘home’ practice because of these new
arrangements rather than register with a university practice? !
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A: Possibly, but it comes down to patient choice and it being clinically appropriate and
practical to be registered away from home. If the student is unable to attend for routine
appointments when needed it is unlikely to be practical. "
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Q: Can patients be assigned to the practice if they live out of area?!
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A: Yes, but not under this scheme. Patients cannot be assigned to practices without
access to home visits. Only GP practices can decide if it is clinically appropriate and
practical to register patients without home visits."
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Q: What about violent patients? If a patient is registered on the Violent Patient
Scheme, would it be appropriate for them to be registered or assigned as an out of
area patient with home visits?!
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A: No. It would not be appropriate for violent patients as this necessitates a stable
environment. Violent patients cannot be assigned in this way because only GP practices
can decide if it is clinically appropriate and practical to register patients without home
visits."
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Q: Couldn’t the out of area patients simply be registered as temporary residents?!
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A: No. In order to qualify as a TR, you have to be residing temporarily in the area i.e.
between 24 hours and 3 months. Out of area patients are permanently resident."
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Q: Would we be paid the same amount when we register out of area patients?!
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A: Yes. You would receive the same GMS global sum/PMS baseline funding, and other
payments (Quality and Outcomes Framework, Enhanced Services etc.) for out of area
registered patients as you would for any other registered patient even though you are not
responsible for home visits. However, NHSE has reserved the right to reduce this in the
future."
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Q: Okay – so we have agreed to register the out of area patient, is there a different
registration process we have to follow:!
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A: Once the decision is made to proceed with registration as an out of area registered
patient the process of registration will operate in exactly the same way as any new patient
registration i.e. "
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The patient completes the GMS1 (or equivalent) registration form"
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The practice enters details of the patient registration onto their GP system as
normal EXCEPT for including a manual note on the registration system using a text string
to identify the patient as out of area. This text strings are not yet agreed locally."
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Details of the registration are processed in the same way as any normal registration
by SERCO and the transfer of the patient’s medical record requested. However, this will
normally be without a change of the patient’s address (unless out of area registration
coincides with a house move)."
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The patient should be provided with information on how to access the urgent care
arrangements commissioned by area teams, in the event that they are unwell at home and
attendance at the registered practice is not appropriate. "
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Patients should be advised that in all circumstances they should seek to contact
their registered practice in the first instance when they need support at home. "
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Q: What are the ‘exiting’ routes?!
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A: Once a patient is registered as out of area patient with no home visiting duties there are
two routes by which their registration may be exited: "
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By the patient - where they no longer wish to be registered, for example because
they want to move to a practice closer to where they live. The patient will simply need to
register with a practice of their choice. "
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By the practice – deregistering the patient on non-discriminatory grounds (but
notwithstanding plans to amend the contract regulations from April to allow removal when
registration without home visits is determined no longer clinically appropriate).
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Keeping in touch with the LMC:
As always, if there is anything you need help with, or if you are looking for guidance about anything in
particular, please do not hesitate to get in touch with us. General enquiries are best sent to
[email protected] and of course there is always the phone 01954 268156
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LMC email lists
The LMC runs several email lists - and here are details of three that you might want to join. Never fear,
leaving a list is just as easy as joining, and none of them are overly busy.
LMC LINK
A private discussion list for local GPs and Practice Managers.
LMC NEWS
An LMC information system - we use this as a way of getting our news to you. This list only gets a few
messages a month, has hundreds of members, and we would love you to be on it too! This list is open to
everybody.
LMC Locum News
An LMC information system for local locums. This is how we help locums keep informed by copying
messages that get sent to practices by others, but don’t always get to the locums!
Please get in touch with [email protected] if you want to join these lists
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Cambridge & Peterborough General Practices are welcome to share this guidance within the area of the
LMC.
December 2014

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