What should GPs do if they don't wish to accept patients from outside their practice boundary?
Many practices will have concerns about this scheme and its potential impact on them. There is however no obligation to participate; the scheme is entirely voluntary for both practices accepting registrations under the out of area regulations or for providing services to patients in their area registered elsewhere under the out of area regulations.
Practices must not therefore feel pressured to be involved in this if they don't want to. Practices should make it clear in their patient leaflet, website or other information available to patients whether they are accepting out-of-area registrations or not. If a practice chooses not to do this they can continue, at their discretion, either to decline to register out of area patients or to register them under the normal regulation with a requirement for home visiting.
Should I register out-of-area patients before a home visiting service is in place for them?
GPC has insisted that NHS England ensures there is a comprehensive service for out-of-area registered patients who are too ill to travel to their new practice. Practices must not register any patient under these arrangements until they are certain that a safe and adequate service is available if patients are too ill to travel to the practice. GPs have a professional responsibility to ensure this is the case.
Does this scheme just apply to practices with commuters in their area?
No. All practices that choose to can register out-of-area patients. This does not just apply to practices in commuter areas, but to all practices in England when patients living outside their current practice boundary want to register with them.
How do I avoid being accused of operating in a discriminatory way?
This is one of the biggest risks that practice face if they choose to engage in this scheme. The usual registration regulations make clear that a practice taking on patients must do so in a non-discriminatory way, including in respect of their medical condition. They cannot just register patients who appear relatively well. However under the out of area regulations they are allowed to refuse to register patients when they believe they have care needs which would be better met through registration with a practice near to where they live. These might be, for example, patients who are receiving a package of home or community-based support which would be difficult for the practice to coordinate remotely or where there are safeguarding concerns. The practice will have to clearly explain to the patient why they are not able to register them.
However, practices are able to refuse some patients that request registration without home visiting while accepting others, as long as they can justify their reasons for refusal on clinical and practical grounds. It is very difficult to argue though that a refusal to register in these circumstances could be perceived as discriminatory. Whilst this is allowed within the out of area regulations, it would be in breach of the usual registration regulation.
It should also be noted that a practice could not refuse to accept the registration of a patient resident in their practice area who wants to re-register with it when they become ill and can no longer travel to their out of area registered practice. Refusal to accept a patient onto a practice list in these circumstances must be in accordance with the existing regulations and must not be discriminatory.
What warnings do I need to give to patients who register as out-of-area?
If a practice accepts an out-of-area patient they need to make it clear what the terms of the registration are, and how they would obtain urgent care should they not be able to travel to the practice. Patients should also be warned that if their health circumstances change, so making out-of-area registration clinically inappropriate in the future, they could be removed from the list. A model letter that could be given to patients can be found in the NHS England guidance at Annex G. GPs should at all times be fully aware of their professional responsibilities when making decisions to register or subsequently remove patients under the out of area regulation.
Will I be contractually obliged to see out of area registered patients as temporary residents or provide them with immediately necessary treatment?
No, out of area patients are recognised as a distinct category, separate from temporary residents. The obligations on the GP practice are therefore different and there is contractual obligation to provide immediately necessary treatment, which should be obtained by the mechanism which has been communicated to the patient, generally involving phoning NHS 111 which will be provided with a directory of which services have been commissioned locally to meet the needs of out of area registered patients.
However the regulations still oblige practices to provide treatment for an accident or emergency whilst in their practice area and there is a risk that out of area registered patients might seek urgent treatment from local practices, placing the practice in a difficult situation of having to assess whether the patient's need for immediately necessary treatment could be construed as an emergency with a requirement to treat them.
What steps should practices take when registering a patient from outside the area?
Practices should have a system to ensure they know which patients are registered with an out-of-area status and the arrangements in place for their out of area care. This will help them to give these patients clear information about the consequences and limits of this registration and will also help the practice respond appropriately to requests from these patients in the future, and monitor whether it continues to be clinically appropriate to continue with this registration arrangement.
How will NHS England regional teams / CCGs commission a local urgent care service for patients registered as out-of-area?
NHS England regional teams and /or CCGs may commission a variety of different in-hours urgent care services to meet the needs of out-of-area patients who are too ill to travel to their own practice. They may commission this from local practices using the model national enhanced service. Practices are under no obligation to take part in this enhanced service. Alternatively the regional team / CCG could commission the service from a single practice or group of practices, from a walk-in-centre or an out-of-hours service provider. Local NHS111 providers will have a directory of local arrangements.
What must the practice do if we take part in an enhanced service to provide services to out-of-area patients unable to travel to their registered practice?
Practices taking up an enhanced service to provide a visiting service to local patients registered as an OOA patient elsewhere will have to ensure their details held by NHS 111 are kept up to date, that they have mechanisms in place to ensure patients receive essential medical services at home as clinically appropriate, and they must 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 but practices should consider carefully whether the fee offered is adequate for the work required and the responsibility involved before taking on this enhanced service. In particular they should bear in mind that some of these patients may have significant medical needs preventing them from travelling to their registered practice, that they will be unknown to the practice taking up the enhanced service and their care will have to be undertaken without access to their medical records.
Can students register as out of area patients?
This is not a dual registration system and would not be appropriate for normal student registration. Although in some circumstances there is nothing in the regulations to prevent practices registering students under these arrangements should a student request it, generally speaking students should be registered under normal arrangements with a practice close to where they live at University and if they need care when they return home they should then be seen as temporary residents.
Can existing registered NHS patients who move out of area be registered as out of area patients without home visits?
No, as long as they are granted continued registration by the practice there would be no change in their status and therefore the duty to visit them at home would continue. Out of area registration with no home visiting duties under the scheme only applies to new patient registrations.
The only way for an existing patient to come under the scheme would be for them to be removed from the list on the grounds they had moved out of the area and then be re-registered under the new arrangements, but subject to the caveats set out above. Patients will at all times need to make an informed choice, which is the responsibility of the practice to ensure.
What is a practice's obligation where they have patients registered without home visiting obligations and patients registered with access to home visits in the same area?
It would depend entirely on the registration status of the individual patient, i.e. whether the patient was registered under pre-existing arrangements with home visiting obligations or under the new regulations with no obligation to visit. The GMS contract regulation does not place any obligation or duty on practices to visit patients who have been registered without home visiting duties. This is because the decision to register without home visits is made on individual basis, so even if a practice had family members living in the same household outside the practice area, individual patients could be registered with or without a home visiting obligation.
Can a dispensing practice dispense to out of area patients?
To be eligible for dispensing services, a patient must demonstrate they would have serious difficulty in obtaining any necessary drugs or appliances from an NHS pharmacist by reason of distance or inadequacy of means of communication; or a patient is resident in an area which is rural in character, known as a controlled locality, at a distance of more than one mile (1.6 km) from pharmacy premises (excluding any distance selling premises). The pharmacy premises do not have to be in a controlled locality. If a patient receives dispensing services from practice A and then registers with practice B, which are both located in a controlled locality, then that patient can continue to receive dispensing services. A controlled locality is an area that has been determined by NHS England, to be 'rural in character'.
If a patient does not reside in a controlled locality, but decides to register with a practice, which is a dispensing practice in a controlled locality, the patient would still not be eligible to receive dispensing services.
What about patients who live in Wales, Scotland or Northern Ireland?
GP practices in England will NOT be able to register patients who live in other countries of the UK as out of area patients without home visiting duties. GP practices will need to decide whether to offer out of area cross border patients the choice of registering with the practice as any other registered patient (i.e. with home visiting obligations) or accessing care as a temporary resident.