registration refused: a study on access to gp registration in … · 2017. 7. 25. · registration...

Registration refused: A study on access to GP registration in England

EveryonelivingintheUKisentitledtofreeprimarycare.GPsareourfrontlinedefenceagainstpoorpublic andpersonal ill-health. They save theNHSmoneyby treating patients early andwell. Yet ahugenumberofvulnerablepeopleacrosstheUKareroutinelyandwronglyturnedawayfrommedicalsurgerieseveryday.For this research themedical charity Doctors of theWorld (DOTW) recorded the outcome of theirattemptstoregisterpatientswithNHSGPsinEnglandbetween4March2015and21October2015.ThepurposewastoreviewtheaccessibilityofGPregistrationforvulnerablepeoplelivingintheUK.

1. Key findings

• Of the 849 attemptsmade by DOTW toregister patients with a GP, 39% wererefused.

• 31% of practices always refused GPregistration and a further 16% gaveinconsistent responses; sometimes theywould register a patient, on otheroccasionstheywouldrefuse.

• ThebiggestbarriertoGPregistrationwasinability to provide paperwork: 39% ofregistrationrefusalswerebecauseoflackof ID; 36% because of lack of proof ofaddress;and13%becauseofimmigrationstatus.

• 23% of registration attempts were met

withmultiplereasonsforrefusal.

• Gatekeeping by reception staff is asignificant barrier to GP registration; in32% of cases the person responsible forregistrationwasnotavailable.

• These barriers are likely to impact onalready vulnerable groups includinghomeless people, asylum seekers,undocumented migrants, children,pregnantwomen,andvictimsof torture,trafficking,domesticandsexualviolence.

2. Context

Doctors of the World’s UK Programme DoctorsoftheWorldUKispartoftheinternationalMédecinsduMondenetwork,whichdeliversover350 projects inmore than 80 countries. Our vision is of a world in which people affected by war,natural disasters, disease, hunger, poverty or exclusion get the healthcare they need regardless ofincomeorstatus.


We’vebeen in theUK for 17 yearswherewe run clinics1 andadvocacyprogrammeswhichprovidebasicmedicalcare, informationandpracticalsupporttopeoplefacingmultiplevulnerabilities.Thosewhocometoourclinicsincludehomelesspeople,drugusers,destitutenationalsaswellasEuropeancitizens,sexworkers,undocumentedmigrants,asylumseekersandRomacommunities.The legal context Access to primary care, walk-in centres and Accident and Emergency, as well as diagnosis andtreatmentof infectiousdiseases,areall free foreveryone inEngland.Thosewhoarenot ‘ordinarilyresident’ in England may be charged for all other types of secondary care. Treatment which isimmediatelynecessaryorurgent2,includingantenatalcare,mustbeprovidedbutmaybechargedforafterwards. However, certain vulnerable groups, including asylum seekers, refugees and traffickingsurvivors,areexemptfromallcharges.

The2014ImmigrationActsetsoutthegovernment’sintentiontomakeit“moredifficultfor‘illegal’3immigrants to live in the UK”. From April 2015, those seeking to stay in the UK formore than sixmonths must pay a healthcare surcharge of £200 per year (£150 for students). The definition of‘ordinarilyresident’waschangedmeaningthatallthosewhodonothaveindefinite leavetoremainarenowsubjecttothecharge.

The Department of Health also introduced theMigrant and Visitor NHS Cost Recovery Programmewhich aims to expand charging and identify more existing chargeable patients. This has led tohospitals routinely asking about someone’s immigration status before they access care and issuingmore peoplewith bills for treatment. The government is currently consulting on extending chargesintoprimarycareandA&E.

GP registration In thepast,guidancetoGPpracticesonregisteringnewpatientshasbeen limited, inconsistentandunclear.In2011,NHSEnglandpublishedpan-LondonguidelinesforGPregistration4whichstated:

• NationalityisnotrelevantingivingpeopleentitlementtoregisterasNHSpatientsforprimarycare

services• Overseasvisitors,whetherlawfullyintheUKornot,arealsoeligibletoregisterwithaGPpractice• PracticesarenotobligedtoaskpatientsforofficialdocumentationinordertoproveIDorproofof

residenceandthereisnorequirementintheregulationsforthemtodoso.• Howeveritisnotunreasonableforpracticestoaskfordocumentationinordertoestablishwhere

apatientlives,andwhoapatientis,iftheychoosetodoso.

ThishasledtovariationinthewaythatGPpracticeshaveinterpretedtheguidelinesandtheirpoliciesregardingproofofaddress,IDandimmigrationstatuswhenregisteringnewpatients.Astheguidelinesare‘pan-London’,GPpracticesoutsideofLondonhavealsotendedtoseethemasnotapplicabletothem.

ClarityoverGPregistrationwasimprovedinNovember2015whenNHSEnglandissuedguidelinesonpatient registration.5 As NHS England is responsible for commissioning and contracting primarymedical services6, this guidancehasbeenwelcomedas theauthorityonGP registration in England.

1 DOTW have a clinic in Bethnal Green and run pop-up clinics in community centres in London. We also run pilot programmes in Hackney and Brighton. 2 http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/496951/Overseas_visitor_hospital_charging_accs.pdf 3 Please note that MdM and its partners, especially PICUM, absolutely disagree with the use of ‘illegal ‘ designing a person. Only the laws saying that a person is illegal are illegal. No one is illegal. http://picum.org/en/ourwork/terminology/ 4 http://www.ealingccg.nhs.uk/media/3499/nhs_london_gp_patient_registrations_operating_procedures.pdf 5 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/11/pat-reg-sop-pmc-gp.pdf 6 From April 2015, 63 Clinical Commissioning Groups (CCGs) took this responsibility from NHS England under a formal delegation agreement.


TheseprinciplesarereiteratedintheBritishMedicalAssociation’sguidanceonpatientregistrationforGPpractices7.AlthoughmostpeoplewillbeabletoprovideproofofIDand/oraddresswhenregisteringwithaGP,thereareanumberofsituationswhereanindividualwillnotbeableto.TheNHSEnglandguidelineslistanumberofsituationswherethismightbethecase:• Peoplefleeingdomesticviolencestayingwithfriendsorfamily • Peopleinunstableaccommodationorstreethomeless • Peoplestayinglong-termwithfriendsbutwhoaren’treceivingbills • Peopleworkinginexploitativesituationswhoseemployerhastakentheirdocuments • PeoplewhohavesubmittedtheirdocumentstotheHomeOfficeaspartofanapplication • Peopletraffickedintothecountrywhohadtheirdocumentstakenuponarrival • ChildrenbornintheUKtoparentswithoutdocumentation DOTW GP registration advocacy work Patients coming toDOTWclinics facemultiple barriers that affect their access to healthcare.Manyalso experience discriminationwhen they try to registerwith aGP. In 2014, DOTWprovided 1,454consultationsandsawatotalof1,395patients(findingspublishedinour2014UKreport8).82.7%ofserviceuserswho came to theDOTWclinichadnotbeenable to registerwithaGP. 29% said thatadministrative problems – such as inability to provide proof of address or ID – had been themainbarriertohealthcareaccess,while12%saidtheyhadbeenrefusedregistration.

DOTWvolunteersandstaffadvocateonbehalfofpatientstoregisterthemwithaGP.In2014DOTWwassuccessfulingetting96%ofpatientsregisteredwithanNHSGP;howeverthisoftentookmultipleattempts. In 2014 we recorded 109 instances where GP practices wrongly refused to register thepatientbecauseoftheirimmigrationstatus.

3. Rationale DOTWdatafrom2014showsalargenumberofGPpracticesrefusingtoregisterpatientsdespitethefactthattheywereentitledtoberegisteredwiththem.Manypracticesthereforeactedasabarrierto7 http://bma.org.uk/support-at-work/gp-Practices/service-provision/patient-registration-for-gp-Practices 8 https://www.doctorsoftheworld.org.uk/files/uk_report_2014_web.pdf

Casestudy [2015]:Lilian isa 23 year-oldwho fledVietnamto escapepoliticalpersecutionaftershe andother familymembers received threats. Shewas brought to theUKby roadby peoplesmugglerswho tookherpassportandhasbeen livingandworking inanail salon for fouryears.LiliancametoDOTW’sclinicwhenshewas10weekspregnant;shehadbeentooscaredtoaccesshealthcarebeforebutwasexperiencingabdominalpainandwasworriedaboutherbaby.DOTWimmediatelysenttohertoA&Ewhereshehadanemergencyscanandreceivedtreatment.

DOTW continued towork with Lilian to help her registerwith a GP and access antenatal care.DOTWvolunteersphonedthreedifferentGPpracticesbefore theycouldfindonethatagreedtoregisterLillian.WhenLilianthenwent intothepracticetoregistershewasturnedawaybecauseshe did not have a passport. By the time Lilian was accepted by a GP practice and startedaccessingantenatalcareshewas15weekspregnant.

Despite experiencing complications throughout her pregnancy, Lilian received good antenatalcareanddeliveredahealthybabyboyat39weeks.


accessinghealthcare.ThisscenariooccurredbothwhenpatientsapproachedGPpracticesthemselvesandwhenDOTWapproachedpracticesonapatient’sbehalf.ForthisresearchDOTWanalyseddataonGPpracticeregistrationsandrefusalsin2015toestablish:• howoftenGPpracticeswererefusingtoregisterpatientswhowereentitledtoberegisteredwith

them;• ifpracticeswerebeingconsistentinrefusingregistrations;and• themainreasonsforrefusal.

4. Method ThisreportanalysesattemptstoregisterpatientswhopresentedatDOTW’sclinics9between4March2015and21October2015.Thedataset includesatotalof849attemptstoregister inGPpractices.AlthoughDOTWclinicsarebasedinLondonandBrighton,wealsoseepatientsfromacrossEngland10. The data was collected by DOTW volunteers whilst trying to register patients with a GP practice.Typically volunteers will telephone the GP surgery closest to the patient’s place of residence11 toestablishwhetherthepracticeisacceptingnewpatientsandifthepatient liveswithinthepractice’scatchmentarea.Theywill then try to secure registrationwith thepracticebasedon thedocumentsthat the patient has. Most patients do not have proof of address or ID. If the practice refuses toregisterthepatientbasedondocumentsavailable,theDOTWvolunteerwill:• informthepracticeofthepatient’svulnerablesituation;• offertoprovideaproofofaddressletterfromDOTW(aUKregisteredcharityandCQCregulated

clinic);and• draw the practice’s attention to the Pan-London based principles regarding GP registration,

remindingthemoftheirobligationtoregisterpatientseveniftheyareunabletoproduceproofofaddressand/orIDandregardlessofimmigrationstatus.

At theendof thisprocess, thepracticeeitheragrees to register thepatient (loggedas ‘registrationagreed’ in our records) or refuses to register the patient (logged as ‘registration refused’ with thereasonforrefusal).

Thetwofollowingscenarioshavebeencategorisedas‘registrationrefused’:• Receptionistcouldnotconfirmregistrationwouldbeallowed• UnabletospeaktoPracticeManager/personresponsibleforregistration

This approachwas chosenbecause, asaminimumstandard, frontlineadministrative staffwho takeenquiries from thegeneralpublic shouldknow thepractice’s registrationpolicy.Any restrictionsonaccess to staff who do know the registration policy is gatekeeping behaviour (the activity ofcontrolling,andusuallylimiting,generalaccesstosomething).

Thedatabeinganalysedincludesthe:• Number of GP registrations agreed - includes practices that agreed to register patients either

withoutanydocumentsorwiththedocumentsthattheyhadhad• NumberofGPregistrationrefusals -arangeofresponsesthatfalloutsideoftheNHSLondon’s

pan-Londonregistrationprinciples• NumberofGPPracticesrefusingregistrations

9 n Bethnal Green, three pop up clinics held at community centres across London, and pilot programmes in Hackney and Brighton 10 In 2014, 11% of people who visited the Bethnal Green clinic had travelled from outside London. 11 If appropriate, a GP practice where a family member or another member of the household is registered will be approached first.


• Reasonforrefusals-categorisedasa)refusalbecauseofnoproofofaddress,b)refusalbecauseof noproof of identification, c) refusal becauseof immigration statusd) gatekeepingbehaviour(i.e. ‘unable to speak to Practice manager/person responsible for registration’ or ‘receptionistcouldnotconfirmregistrationwouldbeallowed’),e)refusaltoregisterpatientsfromDOTW,andf)wouldonlyregisterasatemporarypatient.12

5. Results GP registrations agreed and refused Total number ofattempts toregisterpatients

Registrationsagreed Registrationsrefused

#. % # %

849 518 61 331 39

Of the 849 recorded attempts to registerwith a GP, 518 registrations (61%)were agreed and 331registrationsrefused(39%).Themapsbelowillustratethedistributionofregistrationacceptancesandrefusals.Theyshowthatthemajorityof registrationattemptsare concentratedaroundGreater London.This isbecauseDOTW’spermanentclinicisbasedinLondon.

12 Patients should only be offered temporary registration if they are in the catchment area for longer than 24 hours but less than three months.


Distribution of GP registration acceptances and refusals acrossEngland

Distribution of GP registration acceptances and refusals acrossLondon

Consistency of response from practices Total number of GPpracticesapproached

GP practices alwaysagreedregistration

GP practices alwaysrefusedregistration

GP practices gaveinconsistentresponses

#. % #. % #. % #. %511 100 269 53 159 31 83 16

Intotal511GPpracticeswereapproachedwithregistrationrequests.269GPpracticesalwaysagreedregistration (53%) and 159 practices always refused registration (31%). 159 practices wereinconsistentwhenregisteringpatients(16%);sometimesagreeingtoregisterpatientsandsometimesnot.Reason for refusals


Number ofregistrationrefusals

Reasonforrefusals MultiplereasonsforrefusalgivenN

oproo

fof

address

No

proo

fofID

Immigrati

onstatus

queried

Gatekeep

ing*

Won

’tregister

DOTW

pa

tients

Temp

registrati

ononly

Not

specified

# % # % # % # % # % # % # % # %331 120 36 128 39 42 13 107 32 2 1 14 4 18 5 75 23* Unable to speak to Practice Manager/person responsible for registration’ or ‘Receptionist could not confirm registration would be allowed’

Ofthe331registrationrefusalsrecorded,themostcommonreasonforrefusalwasnoproofofID(128instances, 39%) followed by no proof of address (120 instances, 36%), gatekeeping behaviour (107instances, 32%), immigration status queried (42 instances, 13%), temporary registration only (14instances,4%)and refusal to registerpatients referredbyDOTW(2 instances,1%). 75attempts toregisterweregivenmorethanonerefusalreason(23%).

Example responses from GP practices DOTWvolunteerswriteashortsummaryoftheregistrationattemptwhichincludestheGPpractice’sresponse. These responses show GP practices agreeing to register patients without paperwork, oracceptingalternativeversionsofpaperwork,suchasphotocopiesorlettersfromDOTW.


[Receptionist] was very helpful andagreedtoregister[patient]withminimaldiscussion.

Agreed to register SUwithDOTW letterandphotocopyofSriLankanpassport

Agreed to register with letter fromDOTWasproofofaddress&ID

Very helpful, said had registered DOTWSUsbefore

TheseresponsesalsodemonstratethatsomepracticesimplementpoliciesthatdirectlycontradicttheNHSEnglandguidance:

‘Wanted proof of ID and proof ofaddress.Nonegotiationpossible’‘OnlypeoplewithvalidvisascanregisterwiththePractice.’‘Practice Manager said those withoutleavetoremainintheUKarenotentitledto register with GP practices, and couldonlyattendwalk-inclinicsandthelike.’

‘Onlytreatoverseasvisitorsprivately.’

‘Absolutely refused registration as nophotoID/bankstatement.’‘Said [they] would only register peoplewith visa of two years plus or UKpassport.’‘Utterly unsympathetic, brick wall.Require passport or driving license andformalproofofaddress.Hunguponme.’

Thereareexamplesofadministrativestaffactingasgatekeepers:

‘Receptionist was unsure whetherPracticeManagerwouldacceptminimaldocumentation - said she would askPracticeManagerandthenaskedwhereI was calling from. When I latermentioned DOTW, I was told thedocuments wouldn't be sufficient, andtheyhadheardfrom'us'before.’

‘They askedme to call again after theyhavespokentothemanager’‘Possibleregistration,willconsiderafterreviewingdocuments.’

Andexamplesofpracticesfailingtounderstandtheguidanceandusingexcusestorefuseregistration:

‘We have no reciprocal agreement withthePhilippinesandthisisrequiredforallNHS services because this is a non EEAcountry, we would therefore advise hertoaccessprivateservices.’

‘WearenottakingpatientsfromDoctorsoftheWorld.’

6. Conclusion Everyone in theUK isentitled to freeprimarycare.However,vulnerablepeople facebarriers thatpreventthemfromregisteringwithaGP.Ofthe849attemptsmadebyDOTWtoregisterpatientswith a GP, 39% were refused. This shows a significant number of GP practices implementingregistrationpoliciesthatpreventaccesstohealthcare.A total of 511 GP practices were approached with registration requests. 16% of these were


inconsistent in their response: sometimes agreeing to register a patient and sometimes refusing.This evidence suggests that there is confusion amongst GP Practice staff about entitlement toprimarycare.The biggest barrier to GP registration is the inability to provide paperwork: 39% of registrationrefusals reasonsweredue to lackof ID;36% to lackofproofof address; and13% to immigrationstatus.Thisshowsapoor levelofunderstandingand/orawarenessof thepan-Londonregistrationguidelinesamongststaff.Thesebarriersarelikelytoimpactonalreadyvulnerablegroups,oftenwithseriousmedicalneeds.The incorrect insistence that patients have proof of address presents a barrier to healthcare forhomelesspeople.Individualssleepingrough,livinginahostelortemporarilystayingwithfriendsandfamilyareunlikelytohavetenancyagreementsorutilitybillsintheirname.Refusalsonthegroundsofimmigrationstatusbarvulnerablemigrants,suchasasylumseekersandundocumentedmigrants,fromaccessinghealthcare.Thesegroupsincludechildren,pregnantwomen,andvictimsoftorture,trafficking,domesticandsexualviolence.This isconcerningashealthcareprofessionalsplayavitalroleinsafeguardingtheseindividualsaswellasmeetingtheirhealthneeds.In 32% of cases of refused registration, the practice was unable to confirm whether registrationwouldbeallowedas thepersonresponsible,usually thePracticeManager,wasnotavailable.ThisshowsthatgatekeepingisasignificantbarriertoGPregistration.Thisfigurealsoreflectsthelackofunderstanding of primary care entitlement and GP registration guidance amongst administrativestaffandindicatestheyarepoorlytrainedonhowtorespondappropriatelytovulnerablepatients.Thedataalsoshowsthatasmallnumberofpractices(4%)usetemporaryregistrationasasolutiontolackofpaperwork.However,patientsshouldonlybeofferedtemporaryregistrationiftheyareinthecatchmentareafor longerthan24hoursbutlessthanthreemonths.Thisevidenceindicatesapoorunderstandingofregistrationguidelinesamongstadministrativestaff.This study demonstrates that vulnerable patients facemultiple barrierswhen they try to registerwithaGP.23%ofregistrationattemptsreceivedmorethanonereasonforrefusal,suchasinabilitytoproduceIDandinabilitytoproduceproofofaddress.TherateatwhichvulnerablepeoplearerefusedGPregistrationislikelytobemuchhigherthanthisinreality.ThisdatarecordsattemptsmadebyDOTWvolunteerswhoaretrainedintheNHSEnglandregistrationguidanceandhaveexperienceofadvocatingonbehalfofpatients.OurexperiencetellsusthatwhenvulnerablepatientsapproachGPpracticesthemselves,usuallywithlittleknowledgeofhealthcareentitlementintheUK,asuccessfulregistrationismuchlesslikely.ThesefindingshavefarreachingimplicationsfortheNHSandpublichealth.BarringGPregistrationunderminesthevalueofprimarycareinpreventativeandearlyinterventionmedicine.GPsareourfrontlinedefenceagainstpoorpublicandpersonalill-health.TheysavetheNHSmoneybytreatingpatientsearlyandwellandpreventingadmissiontoexpensiveemergencyandsecondarycare.7. Recommendations

GP practice administrative and clinical staff is trained on entitlement to NHS care. Everyone isentitledtofreeprimarycareregardlessofimmigrationstatus.Partners and Practice Managers ensure registration policies are in line with Standard OperatingPrinciplesfromNHSEngland.ThisincludesaccommodatingforindividualswhodonothaveproofofaddressorID.


Frontlineadministrativestaffreceivestraininginthepractice’sregistrationpolicyincludinghandlingsituationswhereanindividualdoesnothavepaperworkandknowingwhenatemporaryregistrationisappropriate.PracticeManagersandadministrativestaffreceivetrainingworkingwithvulnerablepatients.GP practices ensure their services are accessible for vulnerable individuals and sensitive to theirneeds:appointmentbookingoptionsforthosewithoutaccesstoaphoneortheinternet;interpretersareusedwhenneeded.

registration refused: a study on access to gp registration in … · 2017. 7. 25. · registration...

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