Safe Surgeries New Patient Registration Policy

Introduction

Patient registration is determined by the provisions of the practice GMS or PMS contract and terms of service. This policy is based on the NHS England Standard General Medical Service Contract, the General Medical Services Contract Regulations, Primary Medical Care Policy and Guidance Manual (PGM) and CQC guidance.

Practices are assumed to have open lists unless they have complied with the procedures for list closure as detailed in the General Medical Services Contracts Regulations. Where a practice has an open list it is required to:

accept the registration of a new patient unless it has fair and reasonable grounds for not doing so
accept allocations by the ICB to its list.

The practice can formally close their list to new patients by requesting permission from its commissioner. Formal list closure lasts between three to twelve months, and cannot last less than three months.

In some cases, it may be possible to request an ‘informal’ or ‘temporary’ list closure, lasting less than three months, for example where staffing difficulties result in suspension of registrations being necessary. GMS and PMS contracts do not allow for these types of list closures, but taking into consideration possible risk to patient care, the practice can discuss these circumstances with their commissioner, who can either provide further support or approve temporary closure, if appropriate.

Patient Choice of GP Practice

From 5th January 2015, all GP practices in England are free to register new patients who live outside their practice boundary area, without obligation to provide home visits. This will provide patients with greater choice and aims to improve the quality of access to GP services.

Patients may wish to register as out of area patients to:

register with a practice in more convenient locations, such as a practice near their work or closer to their children’s schools, or they reside within the area during the week, but their permanent address is in another area
stay registered with their current GP if they have moved home but do not want to change GP
register in an area with better access to services

These new arrangements are voluntary for GP practices. If the practice has no capacity at the time, or feels it is not clinically appropriate or practical for patients to be registered so far away from their home address, they can still refuse registration for out of area patients. The practice should explain their reason for refusing registration to patients. When registration is refused, patient choice is not fully realised.

New Patient Acceptance/Refusal

New patients should submit a New Patient Registration/Health Questionnaire and the new style GMS1 Form.

The practice will accept patients onto its list while it remains “open”. If the list is closed, the practice will only accept registrations of immediate family members of patients who are already registered and only if such relatives reside permanently at the registered patient’s address.

For patients who self-declare that they hold either a non-UK issued EHIC, PRC or S1 form, the practice is required to manually record this information in the patient’s medical record and then send a copy of the GMS1 form to NHS Digital – NHSDigital-EHIC@nhs.net (for Non-UK issued EHIC/PRC details) or the Department of Work and Pensions (DWP) overseas.healthcare@dwp.gsi.gov.uk (for S1 forms).

Patients will not be unreasonably refused registration. This includes refusal based on:

Medical condition
Race
Social class
Gender or sexual orientation
Disability
Age
Immigration status
Religious group or religious beliefs
Political beliefs
Appearance or lifestyle

The practice will, however, refuse registration if the commissioner has agreed that they can close their list to new patients. The practice can also refuse registration (subject to a partners’ discussion and agreement) if:

The patient has been previously removed from the list
The patient has a known history of violence
The patient lives outside the practice boundary
If they have other reasonable grounds

The reason for refusal will be in writing and recorded in a permanent record for that purpose. This excludes temporary residents, where no record is necessary. The permanent record will consist of the original GMS1 registration form endorsed with the reason for refusal, together with a copy of the refusal letter, filed in surname order. Where a GMS1 has not been completed, a “dummy” GMS1 will be prepared and filed. The record is subject to inspection by the ICB, who may require the practice to justify a refusal to register.

ID and Proof of Address

There is no regulatory requirement to prove identity, address, immigration status or the provision of an NHS number in order to register. ID and/or proof of address can be requested to assist with the administrative process, but the practice must apply the same process for requesting documents to all patients requesting registration equally. The majority of patients will not find it difficult to produce documents.

However, there will be some patients who do live in the practice area, but are legitimately unable to produce any of the listed documentation. Examples include:

People fleeing domestic abuse staying with friends, family or in a shelter
People living on a boat, in unstable accommodation or street homeless
People staying long term with friends but who aren’t receiving bills
People working in exploitative situations whose employer has taken their documents
People who have submitted their documents to the Home Office as part of an application
People trafficked into the country who had their documents taken on arrival
Children born in the UK to parents without documentation.

Reasonable exceptions need to be considered and the individual registered with sensitivity to their situation. As there is no requirement under the regulations to produce identity or residence information, the patient MUST be registered on application unless the practice has reasonable grounds to decline. Lack of ID/proof of residence would not be considered reasonable grounds to refuse to register a patient and access to appointments should not be withheld in these circumstances. If a patient cannot produce any supportive documentation but states that they reside within the practice boundary then practices should accept the registration.

Where necessary, (e.g. homeless patients), the practice may use the practice address to register the patient, putting CO (care of) at the start of the address (as per CQC and PCSE advice). If possible, the practice should try to ensure they have a way of contacting the patient if they need to (for example with test results).

If a practice suspects a patient of fraud (such as using fake ID) then they should register and treat the patient but hand the matter over to the NHS Counter Fraud Authority (NHSCFA).

Access to online services

It is important to note that whilst there is no requirement for ID when initially registering at this organisation, this should not be confused with those patients that wish to have access to online services. Should any patient request online access, then full identification is required and the process should be followed as detailed within the Access to online services policy.

Temporary Residents

If a patient is resident in the practice area for more than 24 hours, but less than three months, they should be offered the option of registering as a temporary patient. In some cases (e.g. someone housed in temporary accommodation) a prospective patient may not know how long they will reside in the area.

Please note: If there is uncertainty around the length of time a patient will reside in the practice area, NHS England advises that the patient should be registered as a permanent patient. For example, asylum seekers residing in Home Office accommodation should be registered as permanent patients.

Emergency Treatment

All GP practices have a contractual duty to provide emergency treatment and immediately necessary treatment free of charge for up to 14 days. This applies to any person within their practice area who:

Has been refused application for inclusion in the practice’s list of patients
Is not registered with another provider of essential services
Has had their application for acceptance as temporary resident rejected

Immediately necessary treatment in relation to people who are visiting England should be viewed as treatment of new and pre-existing conditions that have become worse during their stay. This is subject to the GP’s clinical judgement.

Support and Additional Needs

If a prospective patient requires additional support in order to register, the practice will do its best to accommodate this. This includes (but is not limited to):

Walking them through the registration process in a more private area of the practice
Using a translator/ interpreter
Noting any accessibility requirements on the patient’s record so that the practice team is aware and can support them as necessary.

Once the patient is registered, the patient may benefit from other forms of support, including but not limited to:

Provision of double appointments
Reducing/ increasing prescription duration as necessary
Promoting clear boundaries for consultations
Providing fast access to a named GP
Waiving normal charges for housing letters or medical reports

Ensuring services are accessible to everyone who needs them is mandatory. This includes following the Accessible Information Standard and provision of interpreting and translation services.

Registering Vulnerable Groups

Children

If a child under the age of 16 attempts to register alone, or with an adult who does not have parental responsibility for the child, the safeguarding lead should be informed.

It is recommended that the GP practice gains assurance by:

Obtaining proof of identity for each child registering (e.g. a passport, or birth certificate). If a child does not have any form of ID, this should not prevent them from being registered. In this case, register the child, but ensure that the safeguarding lead is made aware of the registration.
Ensuring that an adult with parental responsibility is present at registration (and that they can prove parental responsibility).
Offering a child a new patient health check
Obtaining supporting documentation from other official sources (e.g. previous GP, social workers etc).

Where any doubt exists, the GP surgery’s safeguarding lead is to be informed and appropriate actions taken.

People with Insecure Immigration Status

Everyone in England, regardless of their immigration status, is entitled to free primary care and to register with a GP. This includes temporary visitors/ tourists, asylum seekers, refugees and other vulnerable migrants. When registering a patient, do not ask about their immigration status, or to see proof of it. People seeking asylum should be registered as permanent patients.

The GMS1 registration form includes supplementary questions about immigration status. These questions are optional – patients do not have to complete this section if they do not want to and this should be communicated clearly to patients. If a patient does opt to complete this section, they should not be asked to provide proof for the information they have provided.

People Experiencing Homelessness

Individuals experiencing homelessness, those without a fixed address, or afraid to share their address, should be registered under either:

an address of their choosing (e.g. a friend’s address, religious institution, or community centre). Advise the patient that they may receive confidential medical letters to this address, and that they should have the occupiers consent
under the practice address. When registering the patient, enter the full address, including postcode for the GP practice, putting ‘Care of’ at the start of the address. Writing ‘no fixed abode’ in any field will cause
the registration request to be rejected.

Ensure that patients are advised to regularly check for post at the address they are registered at, so as not to miss any important medical correspondence (e.g. secondary care appointments).

Duty to refer

The Homelessness Reduction Act (2017) came into force in 2018. It places renewed emphasis on homelessness prevention. Section 10 requires public authorities in England to notify a local housing authority (LHA) of service users they think may be homeless or at risk of becoming homeless.

This statutory duty to refer applies to:

NHS organisations that provide inpatient care
emergency departments
urgent treatment centres.

It is not mandatory for primary care providers. However, it is still beneficial for GP practices to refer patients who are homeless, or are at risk of becoming homeless, to a local housing authority for further support.

Referrals must include:

the service user name
their contact details and
an agreed reason for referring the user.

You can refer without consent to safeguard children and vulnerable adults. Guidance on the duty to refer can be found here.

Patients About to be Released from Prison

The process for registering patients prior to their release from the “secure residential estate” which includes prison, immigration removal centres, young offender institutions or secure training centres, is outlined here.

Veterans

Ex-service personnel or reservists will be provided with copies of their medical records by DPHC (Defence Primary Health Care) on leaving the Armed Forces and becoming a veteran. These records should be given to their new GP practice on registering.

Armed Forces veterans are entitled to priority treatment if their injury or condition came about because of their service (subject to clinical need). This is regardless of whether they receive a war pension. Further guidance can be found here and here.

When registering veterans, the following SNOMED code should be entered at the time of registration: Military veteran SCTID: 753651000000107. Having this code will enable access to specialist care or charity support as necessary for the patient.

Mental Capacity Act

If a person is unable to register because they are unable to make decisions about their care, registration can be done by:

A relative
The main carer
A lasting power of attorney
A person appointed by a court under the Mental Capacity Act

NHS Health Checks and New Patient Health Checks

All newly registered patients should be offered a New Patient Health Check. Some patients may also be entitled to an NHS Health Check. Please refer to the health check policy for further guidance.

Please also see below patient health questionnaires for people seeking asylum and refugees which can be shared during registration to improve efficiency and effectiveness of New Patient Health Checks.

Further Resources and Guidance

Resources Hub

NHS guidance:

How to register with a GP surgery
Asylum seeker and refugee one-page registration guide
Primary Medical Care Policy and Guidance Manual (PGM)

BMA support:

Guidance on patient registration
Toolkit for asylum seekers and refugees

PCSE support:

PCSE guidance on registration
PCSE contact details and enquiries form

CQC guidance:

Registration mythbusters
Registration of migrants, asylum seekers and refugees
People experiencing homelessness

OHID

Migrant Health Guide

Doctors of the World

Safe Surgeries network
Patient health questionnaires for refugees and people seeking asylum