What is the Patient Choice Scheme?
The Patient Choice Scheme will allow GP practices to register new patients who live outside the practice area, without any obligation to provide home visits or out of hours services when the patient is unable to attend their registered practice.
The scheme also allows patients who are currently registered with the practice, but move out of the area, to re-register as an out of area patient, and with the practice not having home visiting obligations.
The pilot for the Patient Choice Scheme ran during 2012 and 2013 in designated areas in England. As a result of its findings and the recent changes to the GP contract, the rollout of the scheme across the whole of England was set as 1 October 2014.
Read more about our evidence on the pilot
What happened next?
In their reply NHS England acknowledged that they had been unable to secure services for patients who register out of area, but who may need access to urgent care near or at home. As a result, NHS England announced the new implementation date for the Patient Choice Scheme as 5 January 2015.
From that date NHS England intends to have adequate arrangements in place to allow practices to register any patient living anywhere in England and if that address is outside the practice's declared area (including its outer boundary if one has been declared) to have no obligation to visit the patient at home if their medical condition dictates that a visit is appropriate.
GPC will continue to closely monitor the coverage of this NHS England commissioned service to ensure it is comprehensive and safe for practices and patients.
What are the new General Medical Services Regulations?
The new regulations require GP practices to determine whether it is clinically appropriate or practical to accept an application from a patient for out of area registration without the requirement to provide home visits or urgent GP services at their place of residence.
NHS England is responsible for procuring urgent GP services and home visiting should the patient need to be seen in their area of residence. As stated above, whilst the new regulations are already in place, NHS England does not currently consider it appropriate to register out of area patients under the new regulation as, until services for patients that register out of area are confirmed to be in place nationally, the criteria to set aside home visits cannot be met.
Read the GMS Regulations 2014
What GP practices should do
Although the regulations remain in place, a practice should only register out of area patients after they have sought and obtained assurances from area teams that arrangements for urgent GP services including home visits are in place for individual patients at their place of residence.
Practices are therefore strongly advised that they should not currently register any patients under the new regulation.
Practices will continue to have discretion over whether to register any out of area patients, whether under the new regulations, or under pre-existing regulations which still oblige home visiting. Practices should make clear their position on accepting patients who live out of area in their local communications (GP practice website, NHS Choices website, practice leaflet, posters in the waiting room etc.) notwithstanding that each patient must be considered on their individual circumstances.
If a practice decides to register a patient as out of area under the new regulation, the process will generally operate in exactly the same way as any new patient registration in that the patient completes the GMS1 (or equivalent) registration form and the practice enters details of the patient registration onto their GP system as normal. The difference is that they must include a manual note 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" and should be added as free text prior to sending via the LINKS software.
This is crucial as it is the only means currently to identify patients registered without home visiting duties.
Extra care should be taken to include the text accurately as above and in uppercase - no abbreviations should be used.
Details of the registration are processed in the same as any normal registration by the local registration department 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).
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. Practices are advised to ensure they are in receipt of all the required information from their area teams before registering any patients under the new regulations.
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.
Categories of registered patient
There are now potentially five different categories of patient:
- Registered NHS patients
- Out of area patients
- Temporarily resident patients
- Patients requiring immediately necessary treatment
- Patients requiring immediately necessary treatment due to an accident or emergency
Of these, only out of area registered patients registered under the new regulation with no home visiting requirement require an alteration in the way they are managed by the practice. Such patients will be able to access all services provided by the practice, except home visits and immediately necessary treatment needed whilst they are away from and unable to attend the registered practice. (See below the mechanism by which these patients will access urgent primary medical services if unable to attend their registered practice.)
The practice should establish whether it is clinically appropriate and practical to register the patient, based on their individual circumstances. In addition, practices may agree with the patient to contact their current/previous practice for further information if they have any clinical or other concerns about registering them outside their home area, for example concerns around child and adult safeguarding.
NHS England guidance states that GP practices should keep the position regarding no home visits under review and if it becomes apparent it is no longer clinically appropriate or practical the GP practice should, following discussion with the patient, invite them to register with a GP practice closer to where they live or if appropriate offer to re-register as any other patient i.e. with access to home visits etc.
Such a review could be triggered by exceptional use of the services the home area team has put in place to provide urgent care when the patient is unwell and unable to attend the registered practice and increasing use of community services in the area they live. GPC has expressed concerns that such a removal decision could be construed as discriminatory.
Exiting the scheme
Once a patient is registered as an out of area patient without home visiting obligations there are two routes by which their registration may be exited:
- 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.
- By the practice – deregistering the patient, but ensuring that this cannot be construed as discriminatory (discussions are taking place to consider amending the contract regulations from April 2015 to allow removal when registration without home visits is determined no longer clinically appropriate as set out above).
What are the arrangements for patients to access urgent GP services or a visit if they fall ill at home?
Area Teams have the responsibility to commission services for patients who register out of area, but who may need access to urgent care near or at home. It is important to note that this will not be the direct responsibility of registering practices if ATs fail to do so.
NHS England has suggested a number of different approaches to commissioning home visiting services, including:
- Local GP services
- Local GP health services or NHS walk-in services
- Out of hours service provider
Under the pilot a local enhanced service was offered, which has been reviewed and updated to provide a nationally priced enhanced service specification for use by area teams. This national enhanced service is available to download. The enhanced service has not been agreed with GPC. The payment for a home visit under this enhanced service is £60 per home visit and £15.87 for a surgery consultation.
What should an out of area patient do if they are ill at home, and are unable to travel to their registered practice?
These patients will access urgent primary medical care through NHS 111, but will generally be expected to contact NHS 111 only following enquiry with their registered GP practice. If as a result of that enquiry 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, the GP practice to which they are attached remains responsible for discussing the options with the patient, agreeing a course of action and making an appropriate referral.
As this practice may not have knowledge of the services available where the patient resides, all CCGs should ensure there is readily available up-to-date information about the range of community services in their areas that remote GP practices can access via the directory of services held by NHS 111 and NHS Choices. It will be the registering practice's responsibility to ensure that it makes itself aware of the services available in the patient's home area and makes all referrals as appropriate.
GP practices will currently 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 they would for any other registered patient.
NHS England has said however that it is considering whether there should be a reduction in the capitation payments paid for such patients to off-set the additional costs in meeting their urgent care needs when at home. NHS England will review data from the first six months of national implementation to establish the likely on-going costs which would form the basis for setting a possible future reduced capitation fee. Proposals will be subject to discussion with GP.
For further guidance, see our FAQs on practice boundaries and out of area registrations
What are the views of GPC on the Patient Choice Scheme?
We have a number of concerns about the way the scheme will operate, including:
- practices will remain responsible and accountable for the overall delivery of GP care to their registered patients even if they are not responsible for their care away from the surgery and must therefore assure themselves that safe and appropriate arrangements for GP care are in place should out of area registered patients be unable to attend their practice
- the fragmentation and availability of community and social services to these patients, and the potential consequences in respect of safeguarding issues
- potential difficulties in respect of referrals to secondary care services
- the risk that practices will have to make decisions which could discriminate on the grounds of medical condition when determining whether to register patients under the new out of hours regulation, and also when deciding whether to remove out of area registered patients from the practice list
View further guidance on removing patients
- the absence of a Directed Enhanced Service for the care of patients away from the surgery leaving a gap in the legal arrangements for ensuring the commissioning of holistic GP care for patient
- practices may find themselves being asked to provide emergency care for out of area registered patients in their practice area. Whilst the provision of immediately necessary treatment will not be a contractual obligation, the provision of emergency treatment will be, and the distinction may not be clear cut.
If you have any queries regarding this issue, please contact the General practice Committee (GPC) for more details at [email protected]
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