Information about local GP services


Last updated July 2008

All UK residents are entitled to the services of an NHS GP. Throughout the UK, patients can register with any local NHS surgery, provided they are within the catchment area of the surgery in question and the surgery has vacancies for new patients. It is through registering with an NHS GP that patients gain access to the full range of NHS health services in their area, including specialist care.

Information on accessing GP services in different parts of the UK is set out below. NHS patients, technically, now register with a GP surgery, rather than with an individual doctor in the practice, although patients should be able to see the doctor of their choice in most cases, even if they have to wait a little longer to do so. A patient's preference to see a particular GP can also be recorded in their medical notes.

Information about GP services

England
The new NHS Choices website includes extensive information on how the NHS is organised in England. The website explains how the NHS works and the functions of bodies such as Strategic Health Authorities and Primary Care Trusts.

Primary Care Trusts (PCTs) are responsible for the planning and delivery of primary health care services to local populations and are now responsible for around 80% of the total NHS budget.

PCTs have to make sure that a wide range of local health services are provided to the public, including hospital services, dental services, opticians, mental health services, NHS Walk-In centres, patient transport services (including Accident & Emergency) and pharmacies. In October 2006 there was an amalgamation of local PCTs and the number of PCTs in England went down from 303 to 152.

In order to treat NHS patients in a primary care setting, GPs must be included on the Primary Medical Performers List. Doctors who want to join a Performers List must apply to the PCT in whose locality they intend to work. Each PCT is responsible for ensuring that any doctor it admits to its Performers List has the necessary clinical skills and experience to provide primary medical services, and that such skills are sufficiently up-to-date.

In England, local PCTs can provide you with a list of GP surgeries in your area. You can then approach these GP surgeries to see if they are taking on new patients. For the contact details of your local PCT and advice about local health care services, you can ring NHS Direct, the 24-hour NHS helpline, Tel 0845 4647.

On the NHS Choices website it is also possible to do a search of local GP surgeries, dentists, opticians and pharmacies in your area. The site contains a frequently asked questions section on GP services, outlining what patients can expect from their care.

Scotland, Wales, Northern Ireland and Channel Islands
In Scotland, local health services are managed by regional Health Boards. Contact details for all the Health Boards and individual GP practices can be accessed via the NHS Scotland website.

For further advice about GP services, patients can ring NHS 24, the 24-hour NHS helpline service in Scotland: Tel 08454 24 24 24 or visit the NHS24 website.

In Wales, local health services are coordinated by 22 Local Health Boards. Local Health Boards can provide information about local GP services in the areas they cover. A list of all GP surgeries in Wales is available on the NHS Wales website, via the search facility .

You can contact NHS Direct Wales, Tel 0845 4647, for any further advice about local NHS services - or visit the NHS Direct Wales website.

In Northern Ireland, four Area Health Boards are responsible for the overall management of local health services. A list of all the GP practices in Northern Ireland can be accessed on the NHS Northern Ireland website. These practices can be contacted directly regarding registration with a GP surgery.

The Isle of Man and the Channel Islands provide health services independently of the NHS. For more information you can visit the Isle of Man government website, the States of Guernsey government website and the States of Jersey government website.


The GP contract and patients
A new UK-wide contract for GPs came into force on 1 April 2004, changing the way primary healthcare is delivered to patients.

The contract allows practices to be paid, in part, according to the quality of the services they offer to patients. The clinical services provided by GP practices are now classified into one of three categories: essential, additional or enhanced:

  • essential services cover care of patients during an episode of illness; the general management of chronic disease; and care for the terminally ill. These services have to be provided by all practices;
  • additional services such as contraceptive services and child health surveillance, are voluntary, but are provided by most practices;
  • enhanced services such as minor surgery and childhood immunisation are optional for individual practices, although they have to be provided by primary care organisations (PCOs) in the local area. Not all enhanced services are obligatory.

The contract enables GP practices to deliver more specialist services, such as minor surgery, that have traditionally only been available in hospitals.

A more detailed explanation of essential, additional and enhanced services is available in our Parliamentary Unit's December 2006 briefing paper GP contract and workload.

The Quality and Outcomes Framework
The Quality and Outcomes Framework (QOF) in the new GP contract provides additional financial rewards to those practices that deliver agreed levels of patient care, based on a points system.

The emphasis in QOF on achieving better management of chronic diseases, such as heart disease and diabetes, is designed to improve overall health outcomes for patients and to reduce premature patient deaths. Although participation in QOF is voluntary, the overwhelming majority of GP practices take part in the scheme.

The QOF comprises a range of criteria which are grouped into four domains: clinical, organisational, patient experience and additional services. Achievement is measured against a set of evidenced-based indicators where points and payments are awarded according to the level of achievement.

QOF is subject to an annual review, where new clinical areas can be added and clinical indicators amended. The four main QOF areas or domains are:
  • clinical domain: this domain consists of 80 indicators across 19 clinical areas (e.g. asthma, heart failure and mental health);
  • organisational domain: this domain consists of 43 indicators across five organisational areas - records and information; information for patients; education and training; practice management and medicines management;
  • patient care experience domain: this domain consists of four indicators that relate to the length of consultations and to patient surveys;
  • additional services domain: this domain consists of eight indicators across four service areas which include cervical screening, child health surveillance, maternity services and contraceptive services.

The QOF also provides a strong financial incentive for practices to consider their patients’ experiences and views, through asking them to complete an accredited questionnaire.

An overview of the QOF and the full national, regional and practice-level QOF results for 2006/2007 can be found on the NHS Information Centre website.

Accessing GP Services
Everyone who is resident in the UK is entitled to the services of an NHS GP. However, a GP surgery may not accept new patients for a number of reasons. A practice list may not be open to patients because it is either “closed” or “open but full”; (in the latter case, although the surgery is not formally closed to new patients, it is not, in practice, accepting new registrations except in exceptional circumstances).
  • closed lists
Practices which do not wish to have patients assigned to their list by the Primary Care Organisation (PCO) must go through a list closure procedure as set out in the General Medical Services (GMS) contract. A practice must apply to the local PCO or an assessment panel and the closure period will then be either for a maximum of 12 months, or until the number of patients on the list falls below a certain number.

According to the Department of Health only around 2.5% or practices have closed lists (Ref 1).
  • full lists
A GP practice also retains the right, under the new contract, not to register new patients, provided it has reasonable and non-discriminatory grounds for doing so. Such a practice may be unable, routinely, to accept new patients. These “open but full” practices do not have formally closed lists, but only accept registrations in certain circumstances, such as from patients allocated by the PCT or from family members of existing patients.

Though a practice need not announce its intention not to register new patients, it must provide a patient applying to join the list with written notice of this. A surgery must not discriminate on the basis of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.

The Government made a commitment in its 2006 White Paper Our Health, Our Care, Our Say (Ref 2) that within a few years patients would be guaranteed acceptance onto an open list in their locality and that the registration process would be simplified and streamlined.

It was also envisaged that the concept of an “open but full” list would also end, and the existing closed list procedures made simpler to operate. There is now an obligation on PCTs to provide up-to-date information to the public on whether a practice is taking on new patients, the range of services it provides, and its opening hours.

The management of practice lists was recognised as presenting difficulties to GP surgeries when the 2006/7 update to the GP contract was negotiated, and there is advice for GP practices on the BMA website for those practices that are unable to routinely accept new patients.

In a recent Department of Health report on the future of NHS Primary Care in England (July 2008) it is proposed that patients should be able to register with any practice they want to, which could lead to the phasing out of closed and full lists (Ref 3).

If you are experiencing difficulties in registering with a GP, in England you can contact NHS Direct on Tel 0845 4647; in Wales you can contact NHS Direct Wales on Tel 0845 4647; and in Scotland you can contact NHS24 on Tel 08454 24 24 24. These helplines should also be able to assist patients who are experiencing any other difficulties with their local healthcare services.

Appointment systems
Individual GP practices organise their appointment systems to best meet the needs of their patients, taking into account Department of Health (DH) guidance. The NHS website provides information on how quickly patients can expect to be seen by a doctor.

The 48 hour access target recommended by the DH, although not mandatory (and only applying in England), provides that patients should be seen by a member of the practice team within 24 hours (this can include seeing a practice nurse) or by a GP within 48 hours.

In order to meet this access target, thereby ensuring that those who urgently need to see a doctor can do so, some practices offer relatively few appointments that can be booked well in advance. Patients may be asked to ring the practice on the day, to be seen that day or the following day. Under this system, it may not always be possible for a patient to see a named doctor, or a doctor of a particular gender, although practices will always try to take a patient's preferences into account. Most surgeries do, however, offer some advance booking of appointments.

The Royal College of General Practitioners had an Advanced Access model for GP appointments on its website. There is also a PCT guide to improving the GP appointments system on the Department of Health website which patients may find helpful.

The BMA has not produced any specific studies on best practice in appointment systems although 48-hour access to GP services is now classified as an Enhanced Service within the new NHS GMS GP contract. Annex 4 of the contract contains detailed provisions on how GP practices can qualify for funding for improving patient access to GP services.

If you have any questions about the appointment systems at your surgery, you need to raise them directly with the practice manager at the surgery. You can also talk to the Patient Advice and Liaison Service (PALS) at your local Primary Care Trust. A list of PCTs, including contact details for local PALS, is provided on the NHS website.

NHS Scotland has made a similar, separate policy pledge on 48 hour access to primary care services.

Out-of-hours care
From January 2005, GPs' 24-hour responsibility for patient care ended, and responsibility for providing out-of-hours cover in most areas transferred to primary care organisations (PCOs). The official 'out-of-hours' period is from 6.30pm to 8.00am on weekdays, in addition to weekends, bank holidays and public holidays.

The purpose of out-of-hours services in primary care has been defined as being “to meet those urgent patient needs that cannot safely be deferred until the patient's own GP practice is next open”. (Ref 4).

PCOs now commission, and may themselves provide, out-of-hours care for patients. As a result, the pattern of service provision has changed, with a more multi-professional response outside surgery hours, involving nurses, paramedics, social workers and pharmacists, and relying on doctors to a much lesser extent. At all times patients will, however, continue to have access to out-of-hours NHS primary health services.

Patients with health concerns outside surgery hours can contact NHS Direct England, NHS Direct Wales (Tel 0845 4647) or NHS 24 in Scotland (Tel 08454 24 24 24). There should also be a recorded message on every GP surgery's answerphone, advising patients what to do when the surgery is closed.

A summary of the position on out-of-hours care can be found on the BMA website.

Removal of patients from GP lists
The BMA's General Practitioners Committee has produced guidance for doctors on the removal of patients from GP lists. You can find a summary of this advice in our briefing paper on Removal of Patients from their lists (August 2005).

Where a practice has reasonable grounds for removing a patient from its list, for example because they have moved outside the practice area, it must notify the local primary care organisation (PCO). It is also good practice to write to the patient, stating why they have been removed from the list.

However, other than for administrative reasons, or where a patient has been violent or abusive, our guidance states that the removal of patients should be an exceptional and rare event and a last resort, where there has been an irretrievable breakdown in the doctor-patient relationship.

With the exception of violent patients, removal does not take effect until the eighth day after the request from a GP is received by the PCO, unless the patient concerned is accepted by, or allocated to, another practice before this.

Patients also have a right to change their surgery; they do not need to provide a reason to the practice for doing so. The local PCO can provide patients with a list of other surgeries accepting patients in their area.

In September 2004, the Royal College of General Practitioners (RCGP) also issued guidance for doctors and practices regarding removal of patients from GP lists, which can be accessed on the 'Your Surgery' section of their website.

Patients who have concerns about being removed from a GP practice list should take up the matter with the practice manager at the surgery.

You and Your Doctor

Making the best use of your GP appointment
Consultations with your GP are time-limited and to get the most benefit from them it is helpful for patients to be prepared before the meeting and to be ready for a two-way discussion with their doctor.

This means that, wherever possible, patients' health concerns can be fully dealt with during the consultation, without the need for a follow up appointment to discuss any issues a patient may have forgotten to mention during their time with the doctor.

Due to time constraints during some sessions with patients, GP surgeries may only deal with one health problem during a consultation and further appointments may need to be made to discuss other health issues. For a complex problem a double consultation can be arranged.
  • before the consultation
Staff at the GP surgery can, generally, advise patients whether their particular health problem(s) can be satisfactorily dealt with by the practice nurse or another health professional within the surgery, rather than their GP. However, patients do not have to inform reception staff of their health problems if they do not wish to do so, and can specifically ask to see a GP.

Patients should not let apprehension prevent them from making an appointment. Even apparently serious symptoms do not mean that patients have a major health problem; such concerns should certainly not deter patients from visiting their doctor. Doctors will also encounter the full range of illnesses and complaints during their careers, so health issues that are potentially embarrassing will not be new to them.

A patient fully prepared for their GP consultation will receive the greatest benefit from their appointment. For example, preparing notes and a list of the questions you want to ask is useful. If a doctor believes a prescription is necessary they will also need to know the details of any other prescription or over-the-counter medicines that you are taking.
  • while you are with your doctor
Making notes during a consultation can help patients recall the advice provided by their GP. If you are unsure about something or do not understand the language being used, the best time to ask for clarification is during the time with your doctor.

Patients should also make it clear whether they have more than one health problem or symptom, as it is possible that different symptoms can be linked; this could include providing information on a recent holiday, a pre-existing condition, current medication, a diet and/or any changes in life situation. If medicines are prescribed, the course of treatment and possible side effects should also be discussed.

The Patients Association has produced a booklet designed to help patients get the most out of consultations with their doctor entitled You and Your Doctor. The NHS Choices website also includes a guide for patients to help them with their consultations, entitled 'Questions to Ask'.
  • knowing 'your numbers'
Patients can get a better idea of their overall health if they are aware of their 'numbers' in relation to measurements affecting them, such as their blood pressure and cholesterol levels. It is also helpful to understand the results of any clinical tests they undergo, such as thyroid function tests.

Without an idea of what a "healthy" or "normal" result might be, a set of figures alone may not be meaningful and can cause unnecessary concern. Health professionals are always happy to discuss the results of clinical tests with their patients.

While each patient will be different, and factors such as age, weight and presence of pre-existing conditions should be taken into account, patients' awareness about their ''numbers' can act as a general health benchmark.

Several patient organisations publish information on the meaning of the results of some routine tests and the range within which a 'normal' result lies. For example, a card that shows healthy levels for haemoglobin, calcium, phosphate, blood pressure and other biochemical markers can be downloaded from the National Kidney Federation website.

The Blood Pressure Association's Know Your Numbers initiative, and the Stroke Association's Know Your Blood Pressure leaflet also both aim to help the public become better informed about their blood pressure readings.

The NHS Direct website also contains a Health Encyclopaedia which includes entries on cholesterol, blood pressure (hypertension) and pulse, while the Patient UK website contains extensive information on tests and investigations in relation to a number of conditions.

Understanding more about your test results and what they mean will help in any discussions with your GP and other health professionals.

Health Records
A patient's GP records are, technically, the property of the Secretary of State for Health, but members of the public have a right to access original copies of their medical records and can ask for copies of their records under the Data Protection Act. A reasonable fee of up to £50 can, generally, be charged for this service.

Patients' rights to access their records, and doctors' obligations under the Data Protection Act, are set out in separate BMA guidance (Ref 5).

Access to records by patients, confidentiality and the new electronic patient record will be covered in a separate web section in Public and Patients appearing shortly.

Changes to your local GP surgery
A recent Government review of NHS services in England, entitled Our NHS, Our Say and undertaken by Professor Lord Darzi, an NHS surgeon, made recommendations for a strategy to meet health needs over the next five to ten years.

Lord Darzi published his final report on the national review in June 2008. To support the recommendations of Lord Darzi’s report as they relate to GP services the Government has published its vision for primary and community care (Ref 3).

Proposals in these two documents include an extension of the GP patient survey to encourage patient feedback; a wider choice of GP, with patients being able to register online, and having a greater range of options for consulting with their GP (e.g. by telephone or email); more online performance and quality information available on the NHS Choices website; and greater promotion of healthy living.

It is anticipated that everyone with a long-term condition will have there own personalised care plan by 2010; a scheme to allow patients with long-term conditions to hold their own health budgets will also be piloted.

The Darzi Review proposed 150 health centres to be set up in 'under-doctored' areas - described as 'GP-led centres' nationally and as 'polyclinics' in London, to be open from 8am to 8pm, seven days a week

While the BMA welcomes additional provision of primary care services in areas where these were limited, and where local patients and clinicians agree on a proven need, the Association has concerns regarding the impact of imposed polyclinics on family doctor services.

These concerns are outlined in a BMA briefing paper, The impact of polyclinics on family doctor services. The BMA is also undertaking a public campaign on this issue.


References
  1. Andy Burnham MP Parliamentary written answer June 4 2007 Hansard; http://www.publications.parliament.uk/pa/cm200607/cmhansrd/cm070604/text/70604w0066.htm#07060557000053
  2. Department of Health (2006) Our health, our care, our say: making it happen; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4139925
  3. Department of Health. NHS Next Stage Review: Our vision for primary and community care. DH London 2008; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937
  4. Dr David Carson (2000). Raising Standards for Patients New Partnerships in Out-of-Hours Care; An Independent Review of GP Out-of-Hours Services in England. Department of Health. Available at: http://www.out-of-hours.info/downloads/oohreview.pdf
  5. British Medical Association. Access to Health Records by Patients BMA London 2007; http://www.bma.org.uk/ap.nsf/Content/Access2007.

    © British Medical Association 2008

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