This guidance is intended to help practices to ensure the safe provision of core services to patients, while fulfilling their professional duty and contractual obligations. GMS and PMS practices in circumstances of unmanageable workload demands, may need to take steps to safely control their list.
The list management section of the Quality First document provides practices with further guidance on list management such as information on formal list closure and informal temporary suspension of patient registration.
Formal list closure
GMS and PMS practices can apply formally to close the practice list, and may choose to do
so if they find their level of workload is jeopardising their ability to provide safe care for their
registered patients, or to carry out their contractual obligations to meet their patients’ core
See the contract regulations
Practices that do not wish to have patients assigned to their list by the area team must go
through the list closure procedures set out in the regulations (paragraphs 20-29 of Part 2
of Schedule 3). If the area team or the assessment panel approves the closure notice, the
contractor’s list is officially closed to assignments. The closure period will be either for a
maximum of 12 months, or if a range was specified in the closure notice, until an earlier point
in time when the number of patients falls below the bottom figure of the range.
This process requires area team consent. We would however, expect all area teams to take
an understanding and supportive approach to practices wishing to close their lists to ensure
that all decisions are made with due consideration to patients’ and practices’ best interests.
Steps to take when considering the possibility of list closure
- Instead of list closure, is there an opportunity to negotiate with the area team for
staffing support with other services?
- There will be a responsibility on both the practice and the Area Team/LHB (Local
Health Board) to ensure that all options other than closure have been considered.
- Document what options you have considered in trying to address the problems being
faced and the outcomes of those considerations, eg rejected or implemented and
- Discuss your individual practice problems at the earliest opportunity with your LMC
who will provide you with confidential help and support in line with the rules and
- Consider possible impact on neighbouring practices and meet with them including
LMC representation to discuss the problems that the practice is facing.
- Could the neighbouring practices help in some way? Document the outcome of the
discussions for future use.
- Request a meeting with the Area Team/LHB and let them know you will be
accompanied by a LMC representative.
- Discuss with your patient liaison group to explain how and why you have come to this
decision and to listen to any suggestions they may have to ease the pressures.
Informal temporary suspension of patient registration
In addition to the formal list closure procedure all practices have the contractual right to
decline to register any new patients without having to go through the formal processes and
without needing to obtain area team permission. However the formal closure does make it
far more difficult for the area team to be able to allocate any new patients to the practice list.
A practice can decide not to register new patients, provided it has ‘reasonable and nondiscriminatory
grounds for doing so’, (such as protecting the quality of patient services.) In
such cases, the regulations allow practice to refuse to register new patients (Schedule 3, Part 3, paragraph 24).
Should a practice be unable to accept patients routinely, a discussion between the practice
and the area team could take place in an attempt to resolve the situation. This could involve,
for example, additional support being provided by the area team or a formal closure of the
The contractor does not need to make an official declaration of its intention to refuse to
register new patients. It must, however, provide the patient with a written notice as in
paragraph 3 of the extract above.
The area team may still assign patients to the contractor’s list (paragraph 17 of Part 3 of
Schedule 6) as its list is open to assignments within the meaning of the Regulations.
Practices should bear in mind that the area team may ask them to justify the decision not
to register a patient. Practices must ensure that their actions do not discriminate between
patients on the grounds of the applicant’s race, gender, social class, age, religion, sexual
orientation, appearance, disability or medical condition. A written acceptance policy will
enable practices to refute any suggestion of improper rejection of applications.
There are equivalent procedures in the regulations for the devolved nations.
Reduction of practice area
Many practices have already asked their area team to consider reducing the size of the
practice area in order to help bring practice list size and workload down to safely manageable
levels. This change would require a variation in contract and therefore the agreement of the
area team. In considering such a request, the area team will consider the needs of patients,
the availability of alternative practices in the locality and the effect that a practice area
reduction could have on their own workloads, so area teams may not agree, but this option
would work for some practices provided patients can be accommodated elsewhere.
Removal of patients from the practice list
This course of action should always be a last resort, when all other possible avenues of
managing list size and workload have been explored, but where practices still feel they
cannot continue to provide safe patient care and meet contractual obligations.
As with the regulations on refusal to register patients, the removal regulations must be
exercised in an entirely non-discriminatory manner. In practical terms, this means that the only patients who could be considered for
removal would be those living outside the practice area.
Practices could decide that this applies to:
- all out of area patients
- only those lying outside of the outer boundary (should the practice have opted to have
- to all out of area patients residing beyond a certain distance from the practice
- to all patients outside the boundary and beyond a certain travelling time for home visit.
A practice making the decision to remove patients could garner considerable attention from
the local community and media.
Removal of patients from GP lists guidance
Practices deciding to remove patients to manage workload must:
- make sure that their reasons for so doing are entirely reasonable, transparent and
- make sure that they act in a non- discriminatory manner and fully in accordance with the
- make sure that they discuss the matter with their patients/PPG, area team, CCG and LMC,
and ensure that alternative provisions are available and that patients are informed of
these. Communication with patients at all stages is vital
- consider relationships with patients, the public and the wider community. This may include the involvement of the local MP
Practices should also ensure that they seek advice of their LMC when contemplating action of this kind.