Access For Homeless Patients
Anecdotal feedback confirmed our suspicions that most of the GP registrars and receptionists who were asked believed patients must have a proof of address and identity documents (ID) in order to register at a primary health care surgery. This is, indeed, what most of us are asked for when we register ourselves or our families somewhere new. What, then, if you have no ID and no proof of address because you're homeless and had your driver's license revoked or stolen?
The widly held but technically inaccurate belief that someone must have ID and proof of address to register at a GP practice probably stems from the fact that this is reasonable and standard practice to counter NHS Fraud. There have been several cases of people falsifying names/addresses in order to register at several health services in order to obtain medications, notably painkillers. The NHS Counter Fraud Services set out a guide for practices to help them minimise the risk of fraud, including asking for ID (NHS Counter Fraud Service).
In actual fact this is guidance only. The absolute rules are much more lenient, as set out in the National Health Service General Medical Services Contracts Regulations 2014 (NHS England, 2014). These state that:
The Contractor [GP Surgery] may, if its list of patients is open, accept an application for inclusion in its list of patients made by or on behalf of any person, whether or not resident in its practice area or included, at the time of that application, in the list of patients of another contractor or provider of primary medical services.
i.e. A GP surgery can technically accept ANYBODY onto it's list of patients. It does, however, grant powers of discretion so that it is up to the practice to accept or refuse the application. It can only refuse on REASONABLE GROUNDS. It goes on to explain that:
the reasonable grounds [that practices can refuse registration on]...shall include the ground that the applicant does not live in the Contractor’s practice area or that the applicant lives in the outer boundary area.
i.e. one of the reasonable grounds to refuse an application is that the person cannot prove they live within the practice area. Note that this is a reasonable ground to refuse and not an instruction that the surgery just refuse the application.
Regarding temporary patients:
a person shall be regarded as temporarily resident in a place if, when he arrives in that place, he intends to stay there for more than 24 hours but not more than three months.
In conclusion, it is legal and possible to register a homeless patient at any GP surgery without the need for ID or proof of address. The decision is at the discretion of the surgery itself. If people are going to be staying with the surgery for more than 3 months they should be permanent patients.
The Practicalities of Registration
So a surgery can decide to waive the need for proof of address and even ID but how can they retain some form of regulation? What about if the they need to contact the patient via letter (for appointments or invites for vaccination etc)? These are all important questions and feedback has shown that surgeries who provide greater access for homeless patients do things differently from one another, suggesting there is no single 'right' method.
Some ideas about how to get around such problems, taken from other surgeries, are listed below:
These are just options but one real life example of how a mainstream practice organises this is:
Please proceed to HOW TO IMPROVE YOUR SERVICE to read about a possible way of starting to implement some of these strategies at your own practice.
The widly held but technically inaccurate belief that someone must have ID and proof of address to register at a GP practice probably stems from the fact that this is reasonable and standard practice to counter NHS Fraud. There have been several cases of people falsifying names/addresses in order to register at several health services in order to obtain medications, notably painkillers. The NHS Counter Fraud Services set out a guide for practices to help them minimise the risk of fraud, including asking for ID (NHS Counter Fraud Service).
In actual fact this is guidance only. The absolute rules are much more lenient, as set out in the National Health Service General Medical Services Contracts Regulations 2014 (NHS England, 2014). These state that:
The Contractor [GP Surgery] may, if its list of patients is open, accept an application for inclusion in its list of patients made by or on behalf of any person, whether or not resident in its practice area or included, at the time of that application, in the list of patients of another contractor or provider of primary medical services.
i.e. A GP surgery can technically accept ANYBODY onto it's list of patients. It does, however, grant powers of discretion so that it is up to the practice to accept or refuse the application. It can only refuse on REASONABLE GROUNDS. It goes on to explain that:
the reasonable grounds [that practices can refuse registration on]...shall include the ground that the applicant does not live in the Contractor’s practice area or that the applicant lives in the outer boundary area.
i.e. one of the reasonable grounds to refuse an application is that the person cannot prove they live within the practice area. Note that this is a reasonable ground to refuse and not an instruction that the surgery just refuse the application.
Regarding temporary patients:
a person shall be regarded as temporarily resident in a place if, when he arrives in that place, he intends to stay there for more than 24 hours but not more than three months.
In conclusion, it is legal and possible to register a homeless patient at any GP surgery without the need for ID or proof of address. The decision is at the discretion of the surgery itself. If people are going to be staying with the surgery for more than 3 months they should be permanent patients.
The Practicalities of Registration
So a surgery can decide to waive the need for proof of address and even ID but how can they retain some form of regulation? What about if the they need to contact the patient via letter (for appointments or invites for vaccination etc)? These are all important questions and feedback has shown that surgeries who provide greater access for homeless patients do things differently from one another, suggesting there is no single 'right' method.
Some ideas about how to get around such problems, taken from other surgeries, are listed below:
- Register all patients courtesy of the surgery's address itself or a local homeless shelter. This way audit searches for that group of patients remain simple and the size of the list can be monitored.
- Form close links with the local homeless shelter so that patients have their mail sent there and explain this to patients at registration.
- Have alternative methods other than post to contact patients, rely more on mobile phones etc. The practice registration process for homeless patients could be adapted to include the fact that patients consent to be called rather than contacted by post.
These are just options but one real life example of how a mainstream practice organises this is:
- One surgery in a locality proactively registers patients it encounters in it's outreach sessions at the local homeless shelter. Other surgeries are aware of this and signpost accordingly. Once the shelter has been identified that a person is going to stay in the local area for any meaningful length of time, a full registration process can begin. A member of staff from the shelter, who can personally verify a person's identification by this time, attends with the patient to complete the registration documents. The address of the patient is listed as the shelter and all mail is delivered there, for the patient's to access securely.
- A doctor attends the shelter for half an hour each week to talk with patients about any issues that might need the surgery's attention. Same day appointments are then offered at this outreach visit and the patient is asked to attend later that day.
Please proceed to HOW TO IMPROVE YOUR SERVICE to read about a possible way of starting to implement some of these strategies at your own practice.
References
NHS Counter Fraud Service. Guidance to GP Practices on Patient Registration Fraud. http://www.hmr.nhs.uk/attachments/article/82/gp-patient-registration-fraud.pdf
NHS England. Standard General Medical Services Contract. 2014. http://www.england.nhs.uk/wp-content/uploads/2014/05/gms-contract-04-14.pdf
NHS Counter Fraud Service. Guidance to GP Practices on Patient Registration Fraud. http://www.hmr.nhs.uk/attachments/article/82/gp-patient-registration-fraud.pdf
NHS England. Standard General Medical Services Contract. 2014. http://www.england.nhs.uk/wp-content/uploads/2014/05/gms-contract-04-14.pdf