Management of the Practice list of patients (Extract)
This chapter contains:
1.1 GP services are the building block of NHS services because, other than attendance at an Accident and Emergency Department of an NHS hospital, the GP is the gateway by which the vast majority of NHS services are accessed by patients. However the provision of all medical services to patients only usually occur where the patient seeks those services from a GP practice where the patient is registered (although GP practice must provide services to other persons as set out below). There is no obligation on anyone living in England to register with an NHS GP practice. This is a matter of free choice for each individual. But the patient can only generally access services by first getting themselves registered with a local GP practice.
1.2 The legal duty for the NHS to commission GP services rests on the National Health Service Commissioning Board, known as “NHS England”. Section 84 of the National Health Service Act 2006 (“the NHS Act”) provides that NHS England is required to set up “arrangements” so as to provide primary medical services throughout England “to the extent that it considers necessary to meet all reasonable requirements”.
1.3 The wording of the statutory duty means that there is no absolute legal requirement on NHS England to ensure that every individual is able to register with a GP practice which is local to their home. The duty is to set a network of GP services to meet the reasonable requirements of patients, and what is reasonable will depend in part on the resources available to NHS England.
1.4 There are occasions when a person cannot find a GP who is prepared to admit that person to their list (either as a registered patient or as a temporary patient). There can be many reasons why an individual patient may find it difficult to find a place on a GP list of a local practice. There are very occasional circumstances where all local GP practices are full and have closed their lists. In such circumstances NHS England will probably have a duty to secure additional GP services in the area to meet its duty under section 84. However the more common reason why a person finds difficulty in registering with a GP practice is because that person has previously been removed from lists of other GP practices in the area for being violent, offensive or for another permissible reason. Most NHS areas have a reserve facility to provide GP services to patients who have been excluded from the lists of other practices. The details of removal and its consequences are explored below.
1.5 The fact that a patient is having difficulty finding a GP will not usually, of itself, be sufficient to demonstrate a breach by NHS England of their duty under section 84. A breach of the section 84 duty would only be established if NHS England had failed to make a proper assessment of the level of local need for GP services in an area or had not produced a plan to deliver services to meet the identified needs. NHS England cannot form a judgment as to whether it is delivering on its duty to provide services to meet the reasonable requirements of the local population for GP services unless it has knowledge of the needs of the population for those services. That knowledge could be based on a needs assessment or could be judged by the number of practices who are open to new patients in an area (and the number of registered patients per GP).
1.6 NHS England’s role is to commission a GP practice to deliver services to NHS patients. Once the commissioning contract is in place the onus shifts to the relationship between the GP and the individual patient because a doctor/patient relationship will only work if there is a measure of trust on both sides. The patient has to have confidence in the medical practice and, if the patient does not have that confidence, the statutory scheme allows the patient to leave the practice and register with another medical practice. However a measure of trust is also required the other way – namely from the doctor to the patient. This can be a very delicate area in practice because there are conflicting interests. On the one hand the NHS ought not to foist a patient on a GP with whom the practice cannot build any form of therapeutic relationship. On the other hand GPs are delivering public services and so should have a duty to work with any member of the public who wishes to access their services. Teachers and social workers cannot, for example, pick and choose the members of the public to whom they are obliged to provide public services as part of their occupation (paid for by taxpayers money). GPs should certainly not be able to react to complaints by removing a patient from their practice list.
1.7 This chapter explores the legal rules which apply to doctors admitting patients to their lists, removing patients from their lists and the powers of NHS England to force an NHS GP practice to take a patient onto the practice list.
 There are limited exceptions to this approach, particularly for services for those suffering from Sexually Transmitted Diseases. STI clinics can be accessed by patients without a referral from their GP.