Primary care organisations (PCO) across England and Wales have a responsibility to ensure that practice lists only include registered patients for whom the practice continues to be responsible for providing primary medical services. To fulfil this obligation, PCOs engage in list validation initiatives.
There have been incidents recently that suggest patients are being wrongly removed from practice lists, despite this being against the wishes of the practices and the patients, and where patients insist that they have never received any communication from the PCO.
This document sets out guidelines for practices, local medical committees (LMCs) and patients to ensure that patients are only removed from practice lists when it is appropriate.
How list validation works
Active list validation initiatives may involve letters to 'the occupier', particularly at multiple occupancy addresses and are normally written in English. Patients will often be flagged if a letter is not replied to and is returned to the PCO (these may include 'gone away' or 'address not known') - automatically triggering what is known as an FP69 Prior Notification transaction.
If a response to the notification is not received, and the expiry date has passed, the patient may be removed from the GP’s list the next time the FP69 Prior Notification transaction run is initiated by the PCO or agency acting on the PCO's behalf.
FP69 refers to the Green Cards that used to be sent to practices by PCOs, after they had received information such as a returned letter, which indicated that a patient no longer lived at an address. In most areas these are now sent electronically and practices receive them as incoming messages on their clinical IT system. Upon receipt of an FP69, a practice is given six months to verify that a patient remains on the practice list.
The PCO will otherwise remove the patient from the practice list at the end of that period of six months.
See Schedule 6, Part 2, Paragraph 24 in the English (page 45)
See Schedule 6, Part 2, Paragraph 24 in the Welsh (page 52) National Health Service (General Medical Services Contracts) Regulations 2004, which states:
’Where the address of a patient who is on the contractor’s list of patients is no longer known to the Primary Care Trust (now the NHS Commissioning Board or 'The Board') and Local Health Board, the Primary Care Trust and Local Health Board shall –
(a) Give to the contractor notice in writing that it intends, at the end of the period of six months commencing with the date of the notice, to remove the patient from the contractor’s list of patients; and,
(b) At the end of that period, remove the patient from the contractor’s list of patients unless, within that period, the contractor satisfies the Primary Care Trust and Local Health Board that it is still responsible for providing essential services to that patient.’
A practice may respond to an electronic FP69 Prior Notification transaction in a number of ways:
- amendment transaction – either to advise the PCO of a change to the patient’s registration details (e.g. new address), or to stipulate in the free text field the possible reason for the lack of response from the patient
- request for Deduction transaction – to have the patient removed altogether
- no response at all – allowing an FP69 Prior Notification transaction run to automatically deduct the patient
The borough or PCO will usually pay for the services of a separate agency to manage and operate FP69 Prior Notification transactions.
One of the problems with the above system is that if letters are addressed to ‘the occupier’ and only written in English, there is a high probability that some patients will not read or understand the letter they receive. Whilst it is recognised that primary care financial resources are finite, and must be invested in the most efficient ways to provide high quality care to patients, it is imperative that practices and PCOs work together to ensure that patients are not removed from practice lists erroneously.
Guidance for practices
Identify and action FP69 notifications from the PCO
PCO list validation initiatives may generate huge numbers of flagged patients. To avoid FP69 flags piling up, practices should have systems in place ensuring that they check their clinical IT system on a regular basis. Practices should use the six-month window provided in the regulations to avoid incorrect patient deductions. Having to re-register a patient means the loss of capitation for at least one quarter.
There is currently no consistent list validation policy across England. Local agreements are often reached between LMCs and the PCOs, and practices should ensure that they are fully informed about these. These agreements will state what evidence the PCO requires to demonstrate that a patient is legitimately registered at the practice and help practices follow the correct process if they need to challenge FP69s.
Practices should look out for their LMC newsletter items or e-alerts regarding local list validation initiatives. In order to keep the LMC and GPC informed, practices should also let their LMC know if they hear about increased list validation activity.
Train your staff
There have been reported problems with the agencies that have been contracted by PCOs to carry out practice list validations. On occasion, it appears that they have not adhered to local policies and lack a clear understanding of the relevant regulations and logistics of general practice.
However, there have also been cases where practices have not been actioning their FP69s regularly and finding themselves in the position of having hundreds of patients being removed from their list.
Relevant practice staff therefore need to be aware of local list validation processes, FP69s and what they mean to the practice.
If designated practice staff are not sure how to identify and action FP69 notifications, they should be trained in how to do this as a matter of urgency. Practices should:
- have designated staff members who are trained in how to recognise the FP69 notifications. This may be the practice manager or another staff member. A deputy should be available to cover any absences
- ensure that all clinicians and staff members notify the practice manager, their deputy or designated staff member immediately if they have evidence that a patient that has been flagged under an FP69 notification, but is still receiving services and is still living at their registered address
- know how to look for FP69 notifications on their particular clinical system. On some clinical systems the notification may not be immediately obvious when generated
- keep a list of all flagged patients and their registration status
- use posters, repeat prescriptions, local media and the practice website to warn patients that their registration may be at risk if they do not respond to letters from the PCO or its agent, and advise them what to do to avoid being removed from the practice list
Avoid unnecessary removals from the practice’s patient list
If a practice believes that a patient has been removed incorrectly from the practice list, they should contact the PCO and inform their LMC as soon as possible. They should:
- insist that the PCO deal with the matter – it is the PCO’s statutory duty and they must ensure this is addressed by them or any agency to which they have delegated authority
- support their patients to appeal by providing them with the relevant names and addresses of PCO senior officers
Practices should not place themselves at risk, so they need to ensure that when they make a declaration to the PCO that a patient should remain on the list, they, as the regulations state (see section 2 above), are in a position to satisfy the PCO that they are still responsible for providing primary medical services to the patient. This should involve the practice providing a statement to the PCO that they are still responsible for providing services to the patient, and that the patient has confirmed their address to the practice.
Guidance for Local Medical Committees (LMCs)
What LMCs can do on behalf of practices?
- the LMC should continue to require that the PCO provides an avenue for patient information, concerns or complaints – LMCs should insist that patients are made aware that PCOs are required to validate practice lists on a regular basis
- request to see copies of contracts and service level agreements (SLAs) for list validation services (i.e. when PCOs delegate authority to undertake local list validation to an agent)
- mediate with regard to disputes on inappropriate removals of patient(s) from practice lists and negotiate compensation where appropriate
- keep list validation and FP69 processes on agendas for LMC, Cluster and Subcluster meetings and continue to emphasise principles for list validation with PCOs and agents acting on behalf of PCOs
- where and when appropriate, continue to inform local authorities and other bodies of any breach of confidentiality, equality and discrimination arising from FP69 processes
- continue to remind GPs, practices and PCOs of local issues and act as a central point for gathering information and evidence where any failures of process occur
- advise and support practices on the contract dispute mechanism should other avenues fail.
Guidance for patients
What patients can do if they have been removed for their practice list in error?
- in order to avoid the FP69 process being started, patients should inform their practice of any change of address
- information from PCOs such as a returned letter may indicate that a patient no longer lives at that address – patients should look out for and, if necessary, respond to such correspondence
- where the PCO has given notice to the practice that they are going to take the patient off their list, the practice will need to satisfy the PCO that it is still responsible for providing the patient with essential services – patients should respond to practice requests in relation to this in order to avoid being taken off the practice list
- where the PCO plans to take the patient off their list, patients can complain to the PCO. When doing so, they should tell the PCO:
− if they have been removed from the practice list, but did not receive a letter
− if they did receive a letter, but it was not addressed to them personally (e.g.‘The Occupier’)
− whether the letter was clear about what they were being asked to do
− if they responded to the letter but were still removed from the list
− whether they have consented to being removed from the practice list or if it is against their wishes
- patients can also contact their local PALS or patient advocacy service for support and assistance, although it is expected that all erroneous patient removals from practice lists would be resolved between the practice and the PCT as soon as possible
- if all other avenues fail, patients can write to their MP detailing what has taken place