There is no obligation to participate in this scheme – practices can choose whether to register out-of-area patients.
Out-of-area patients can access all services from your GP practice except home visits and urgent treatment.
NHS England is responsible for procuring urgent GP services and home visiting should a patient need to be seen where they live. In most areas this will be delegated to CCGs through co-commissioning arrangements.
Practices should only register an out-of-area patient after they have got assurance from the regional team or CCG that these arrangements are in place where they live.
The BMA is monitoring the coverage of these services to ensure they are comprehensive and safe.
This is not a dual registration system and would not be appropriate for normal student registration. Students should be registered with a practice near their residence at university. If they need care while at home they should then be seen as temporary residents.
Patients who move out-of-area
As long as the patient is granted continued registration, there is no change in their status and the practice is still responsible for home visits.
Out-of-area registration under this scheme only applies to new patient registrations. For an existing patient to come under the scheme, they would have to be removed from the list on the grounds that they moved, then re-registered as out-of-area. At all times, patients should make an informed choice.
The practice should establish whether it is clinically appropriate and practical to register each out-of-area patient based on their individual circumstances. They may agree with the patient to contact their current/previous practice for further information if they have any concerns, for example around child and adult safeguarding.
When you have determined it's appropriate for the patient:
- the patient completes the GMS1 (or equivalent) registration form and the practice enters the details into the system as normal
- a manual note is put on the registration system using an agreed text string to identify the patient as out of area
These text strings are: ‘OUT OF AREA REG’; ‘OUT OF AREA SCHEME’; ‘OOA REG’; ‘PC-OOA’; ‘PCS-OOA’; ‘OOAR’. They should be added as free text before sending via the LINKS software. Make sure they are entered exactly as above.
- the registration is processed as normal by the local registration department – and, if necessary, the transfer of the patient’s medical record is requested – except without a change of the patient’s address, unless the registration coincides with a house move.
Practices should have a system to ensure they know which patients are out-of-area and their arrangements.
This will help to give those patients information about the limits of their registration, to respond appropriately to the patients’ requests, and to monitor whether it remains clinically appropriate.
Patients should be warned that if their health circumstances change they could be removed from the list in future.
Home visits and community services
Patients should be advised to contact their registered practice when they need support at home, but they should also be given information on how to access the urgent care services in case they need it.
Patients can access urgent primary medical care through NHS 111, but are generally expected to do so only after speaking to their registered GP practice. If the GP thinks a face-to-face consultation is necessary, the patient will be advised to ring NHS 111.
If community-based services are required by the out-of-area patient, their GP practice remains responsible for discussing the options with them, agreeing a course of action and making a referral.
All CCGs should ensure there is information available about community services in their areas, which GP practices can access via the directory of services held by NHS 111. It is the practice’s responsibility to make itself aware of the services available in the patient’s home area.
For an out-of-area patient to be eligible for dispensing services, they must show that they would have serious difficulty in getting drugs or appliances from an NHS pharmacist. This could be because:
- of distance
- no means of communication
- they are resident in a rural area known as a controlled locality, at a distance of more than one mile (1.6km) from a pharmacy (excluding distance selling premises).
If a patient receives dispensing services from practice A and then registers with practice B, both located in a controlled locality, then that patient can continue to receive dispensing services. If a patient does not live in a controlled locality, but decides to register with a dispensing practice which is in a controlled locality, they would still not be eligible to receive dispensing services.
Avoiding accusation of discrimination
This is one of the biggest risks practices can face in this scheme. Practices cannot discriminate based on factors including medical condition. Under the out-of-area regulations, however, they are allowed to refuse to register patients whose care needs would be better met by a practice near their home. This could be patients who receive home support which would be difficult for GPs to arrange remotely, or where there are safeguarding concerns.
The practice has to clearly explain to the patient why they are not able to register them.
Practices can refuse some out-of-area patients while accepting others. They need to be able to justify their reasons for refusal on clinical and practical grounds.
A practice could not refuse to accept the registration of a patient living in their practice area who wants to re-register when they become ill and can no longer travel to their out-of-area registered practice.
Providing services to other practices' out-of-area patients
If your practice takes up an enhanced service to provide a visiting service to local patients who are registered elsewhere, you must:
- ensure your practice details held by NHS 111 are kept up to date
- have mechanisms to ensure patients receive essential medical services at home as clinically appropriate
- have a robust system to transfer information about care given to the patient’s registered practice within 24 hours of the consultation.
If the model enhanced service is used, a fee is paid for each consultation. Practices should consider carefully whether the fee offered is adequate for the work and the responsibility involved. Bear in mind that some patients may have significant medical needs stopping them from travelling to their practice. That might be unknown to you, and their care will have to be undertaken without access to their medical records.
The BMA view
The BMA GPs committee has a number of concerns about the patient choice scheme, including:
- practices remain accountable for their registered patients, including away from the practice, and must therefore be assured that appropriate care arrangements are in place
- the availability of community and social services to these patients, and the potential issues, eg safeguarding issues
- the lack of clarity from many CCGs about their locally commissioned home visiting service
- potential difficulties in referring to secondary care services
- the risk that practices will have to make decisions that discriminate on the grounds of medical condition when determining whether to register/remove an out-of-area patient
- the scheme being used to ‘cherry pick’ young and healthy patients from other practices for out-of-area registration, which risks undermining the registered list system and destabilising practices that lose large numbers of patients
- the absence of a directed enhanced service for the care of patients away from the practice leaving a gap in legal arrangements for the commissioning of holistic GP care
- practices may be asked to provide emergency care for out-of-area registered patients in their practice area - while immediately necessary treatment will not be a contractual obligation, emergency treatment will be, and the distinction may not be clear.