Our patient registration dilemma: chronology


2004   Introduction of new GP contract. A number of aspects very welcome. One problem is that we cannot limit our practice list size. We must register anyone who wants to join, provided they live in our practice area.

We struggle with this. Our list size grows inexorably. Working hours expand. I go to work at weekends to catch up, try to stay on top of things.

2007 (?)   The PCT calls an emergency meeting. Tower Hamlets has performed poorly in a national poll on patient access. The poorest performers are categorised ‘Red’, the next ‘Amber’, those doing well ‘Green’. Our practice is one of the six green practices.

I go to the meeting and say this: ‘I shouldn’t be here as we’re green, we’re not a problem. But we have a really big problem. This business of having to take all comers, you might as well come and drop a hand grenade into our practice…’

They have other fish to fry that day.

2008   We agree with the PCT to increase our list size by 400 (up to 3,516 patients). The PCT gives us some money up front to do this. We undertake building works to create an additional consulting room.

The building work is stressful. The cost exceeds our grant. The list size grows. The workload grows. We take on addional administrative and nursing staff.

 2009    April. We near our agreed list size of 3,516. So what happens now? I cannot go on like this. We receive the PCT Patient Registration document reminding us of our contractual obligation to register anyone.

I decide to name the new consulting room The Bateson Room after Gregory Bateson (see Wikipedia), because of his work on the functioning of systems, the importance of being systemic.

May. I make some notes on the back of an envelope. I write my 4 page document. I am beginning to wake up to the fact that this requirement is not only a pain in the bum but actually a systemic flaw that, if followed, actually leads to malfunctioning and destruction of the system. I send the document to the Local Medical Committee.

I remember that Gergory Bateson also came up with the double-bind theory of schizophrenia.

I decide we will not grow larger than 3,520. I will resign if forced to do so. Nobody in the practice says we should grow though there is some disquiet that we should ‘break the rules’.

Response from LMC.

I send my document to PCT. One question I ask: “I am told that this is government policy, that this comes from on high at the DOH. So you at the PCT are just following orders. Would you be able to tell me who at the DOH has responsibility for this? What department deals with this? Which minister deals with this? Is there a review body within the DOH which evaluates or reviews policy?” I received no answer to these questions.

We continue to register patients when we have capacity.

November. I am invited to a meeting at the PCT, for the PCT to hear from practices. Practice managers, GPs, the PCT medical director. The PCT managers are there to ‘listen’. When it is my turn to feedback, I say this (abbreviated format): “I went into general practice to do a good job, to offer a quality service. This policy of having to register all comers makes this impossible. It is a f**king bonkers policy. I know you can’t tell the people further up the planning chain this because your careers would not be helped. You have rubbed our faces in the sh*t since 2004. I refuse to grow any further; I refuse to die for your f. bonkers policy. I will resign if you try to force us on this, but before I go I will explain to our patients and they will tell you what they think.” After the meeting, the medical director says to me: the managers are in shock.

We continue to register patients when we have capacity.


May. I receive an NHS booklet on achieving good quality care. I spend time tracking down the email address of one of the authors and send him an email: it is all very well to urge us to aim for quality care, but you have to make sure there are not policies that undermine this. He forwards my email to the National Director for Primary Care at the DOH.

July. I meet D., the National Director for Primary Care, a retired GP. I outline the difficulty posed by this requirement to register all comers. He agrees that this is an unsustainable situation; but he says this is a local misinterpretation of national policy. He offers to speak to A. at Tower Hamlets PCT. I say that we have sorted our problem, we are just refusing to obey this directive. But I am concerned that others are having to work with this policy. I say my impression is that this is a national policy. I ask who is responsible for this, who should I speak to at the DOH. D. does not know. He does not offer to find out and try to sort this problem out. I mention my concerns about the proposed policy to register with a GP anywhere in England. He says it would suit him as he spends a lot of time in London.

July/August   I carry out an email correspondence with the BMA (General Practitioners Committee). They say that our registration dilemma is a national issue; they sympathise with our quandry, but advise that the only thing we can do is shrink our practice area, or close our list. They advise that we keep quiet about what we are doing.

We continue to register patients when we have capacity, aiming to maintain a list size as close to 3,520 as possible. We do not select whom we register.

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