NHS list cleansing and the financial impact on GP practices

By Gemma Harmon, Business Services Manager, Armstrong Watson 

NHS England's current programme of patient list validation is intended to improve the accuracy of GP registration records by identifying patients who may no longer live at their registered address or remain eligible for inclusion on a practice list. While maintaining accurate patient records is an important objective, the scale and pace of the current exercise is causing significant financial and operational concerns for some GP practices.

Practice costs are largely fixed and general practice cannot rapidly reduce expenditure if income falls unexpectedly. Staff costs and premises costs tend be the biggest practice expenditure and sudden drops in income can impact practice sustainability.

Whilst list cleansing is a routine administrative exercise, the scale, nature, and intensity of the current programme may result in sudden list size reductions, with a direct impact on global sum income (baseline income for PMS contract holders), cash flow and practice resilience.

List sizes matter and removing genuinely inactive registrations is a legitimate objective. Historically, the number of patients registered with a GP has exceeded the UK population estimates as provided by the Office of National Statistics for a variety of reasons, such as patients being on multiple lists as they transfer between practices, overseas patients, and delays removing deceased patients.

It is, however, vital that the process of list cleansing is not rushed as errors often affect the poorest areas most, stretching already underfunded and overworked GPs. These reductions cause unexpected drops in funding that affect staffing plans, partner drawings, premises affordability, and the costs of increasing capacity.

The wider financial consequences

The impact of large-scale list cleansing is not just the immediate reduction in global sum, many other elements of GP finances are impacted by list size, including:

• How PCN funding streams are allocated, as many PCN allocations are based on combined registered list size
• Enhanced services and capacity funding, where eligibility or expected activity levels are linked to registered populations
• The cost in staff time of monitoring and correcting errors, dealing with complaints

Patient safeguarding

There is also a significant patient safety risk. If the most vulnerable patient groups are removed from lists incorrectly, there may be significant disruptions to their care. Those most at risk include vulnerable people experiencing homelessness or unstable housing, patients with severe mental illness, learning disabilities or complex long-term conditions, older people moving between care settings, and individuals who face communication or language barriers. 

This will not only increase the cost to primary care to correct these errors, but will also cause these patients to attend a hospital setting instead.

What can practices do?

1. Monitoring list size – establish the current list size, identify and review all recent deductions to ensure they were appropriate and, where necessary, challenge these deductions.
2. Strengthen the FP69 ^[1] monitoring process – allocate as a key responsibility to monitor FP69 flags, log all FP69s, track deadlines and prioritise review and response.
3. Challenge inappropriate removals – contest deductions quickly and provide evidence within the objection window, noting that this has been reduced from six months to three months.
4. Identify your most vulnerable patients - contact patients most unlikely or unable to respond who may be incorrectly removed from the practice list.
5. Record any issues that arise as a result of list cleansing - where there is harm or near-miss incidents as a result of incorrect removal, feed this into practice governance systems, LMC reporting and significant event analysis.

The objective of list cleansing should be to ensure that the right patients remain on the list, particularly those who are least able to advocate for themselves, not just a mechanism for reducing raw list sizes.

Funding follows a patient’s need and practices need to approach list cleansing with both patient care and financial stability in mind. Patient need does not vanish when a patient is removed from a GP list. Care often shifts to other parts of the NHS, placing additional demand on already overstretched services. While these services may be the most accessible option for patients, they are not always the most appropriate, potentially leading to poorer outcomes, fragmented care and higher costs across the wider health system.

The impact of the ‘List Validation’ exercise is far-reaching. There are indications that there will be support for those practices most at risk, but given the staffing reductions at Integrated Care Boards (ICBs) alongside uncertainties around the new neighbourhood network model, this support may be difficult to access.

Practices need to undertake proactive monitoring and challenge wrongful removals. List accuracy is important but not at the expense of patient care, financial stability and the sustainability of frontline general practice.

*FP69 is a market set on a patient's Personal Demographic Service (PDS) record when there is uncertainty about their registered address, often following returned mail, or failure to respond to requests to confirm their details. Once an FP69 is issued, practices have a limited period (now three months) to contact the patient and confirm their information, before the patient may be deducted from the practice list.