Patient List Size
The National Patient Register, which is collected by NHAIS, is intended to be an accurate count of individuals registered with each General Practice. Among other benefits, accurate patient lists should ensure that the appropriate payments are made to practices for patient care.
However, there is a known discrepancy between the estimated size of the England population and the number of people registered at GP practices which is known as list inflation, over-coverage or ghost patients.
List inflation occurs when the National Patient Register continues to record individuals that should have been de-registered. This can happen for a variety of reasons, including - but not limited to:
- Patients move away and do not de-register when they leave
- Young, healthy people have moved to a new address but did not prioritise de-registering with their former GP practice
- Patients have left the country but did not de-register
- Shared custody of children with split residence is not flagged in the medical record resulting in double-counting
- Duplicate records, for example due to use of different names, particularly surnames
- For example, children are recorded against their mother’s and their father’s surname, resulting in double-counting
- Patients in nursing or residential care are registered for that address as well as their original place of residence
In addition to list inflation, which incorrectly increases the count of patients, there are also issues associated with under-coverage. For example:
- Individuals move to a new area, de-register from their former GP and do not register with a new practice in a timely fashion, if at all
- Members of the armed forces and their families are included in population estimates but are not covered in the National Patient Register. However, from a statistical perspective, adjustments are made to mitigate the effect of this
- Babies may not be included in the National Patient Register until formally registered
- New (or returning) migrants may delay registration with a practice
- Individuals may be inappropriately removed from a GP list under the “no-contact” criteria and may need to be restored
There are a large number of collection systems providing GP practice data to NHAIS, with variation in the quality of the data recorded, and in the verification and checking mechanisms in place.
In terms of patient information, there are a range of data quality considerations – such as when hand-written records are added to electronic systems – which could contribute to over or under-coverage.
Weighted patient counts
The weighted patient count is a constructed value that is used in the practice funding formula (the Carr-Hill formula). It considers the following six indices which are then applied to the registered patient count:
- Age and gender
- Patient need (morbidity and mortality)
- List turnover
- Market forces
- Patients in nursing or residential homes
The weighted patient count is therefore a calculated count based upon the needs of the practice’s registered patient population.
Patient list counts in the NHS Payments to General Practice publication
For the purposes of this publication, the registered and weighted patient counts are the average of the counts at the end of each quarter (30 June, 30 September, 31 December and 31 March).
In releases prior to 2018/19, the most recently available patient counts were used, so the count at the end of quarter four was used unless no count was available (for example because the practice had closed), whereupon the count from quarter three, two or one was used.
However, use of the most recent patient count can result in additional double-counting of individuals within the data beyond the issues outlined above in “list inflation”. For example, practice A may close at the end of quarter one. All patients registered at that practice will be counted against that practice along with the payments made while the practice was open. However, the patients may subsequently register with a new practice and will be counted against their new practice in later quarters thereby inflating the overall totals.
Some practices received payments from ISFE only and no information is available relating to patients that may be registered with these practices. As a result, no practice-level figures can be calculated for average payments per registered and weighted patient at these practices. However, the total money paid to these practices is included in the calculations of average payments at a CCG and national level, which again means that these measures should be treated with caution due to the uncertainty relating the patient counts used in the denominator.
Finally, as a result of the uncertainty described, CCG and England-level figures for average payments per weighted patient are likewise subject to comparable levels of uncertainty.
Some practices show no registered or weighted patients but nonetheless provide healthcare services and receive payments accordingly; these practices are identified by a “No registered patients” flag in the Atypical Characteristics column and by “N/A” in the average payments per registered patient and weighted patient columns.
The NHS England and NHS Improvement regional structure is subject to change, generally at the beginning of the financial year.
Figures are provided for practices, CCGs and regions according to the structure during the reporting year in question. This is to avoid any confusion which could be caused by reporting payments made during the reporting period in terms of a new structure, where characteristics of practices could differ between then and now. These could include differences in:
- practice details (such as name)
- the practice’s CCG or NHS England and NHS Improvement region
However, it may be the case that as a result of a restructure, some CCGs or regions may no longer exist.
The data tables in the report include some negative amounts. The data is extracted from NHAIS and ISFE based on the payment code used at source. Adjustments can be required to these codes for a number of valid reasons, including rectifying the use of an incorrect code. As adjustments can be either positive or negative this can result in what appears to be a ‘negative payment’.
- As some payments are made on account, negative payments may also occur where there has been an overpayment in a previous period and the money has subsequently been recovered.
- Similarly, some ‘deductions’, for example for pensions, levies and prescription charge income, could be positive amounts, once adjustments have been made.
Where a zero is shown, there is no payment for that category for the practice; it does not signify missing or unavailable data.
Additionally, some payment categories may be removed, added or altered year-on-year to reflect any changes made to services and how they are paid for.
The data provided is analysed according to the coding allocated at the time of payment via NHAIS or accounts payable in ISFE. These payments codes may be subsequently changed as part of normal accounting processes. However, as data is extracted from source data rather than the general ledger it is not possible to replicate such modifications to the data.
Global sum makes up the bulk of payments to practices. It is calculated based upon each practice’s patients according to the Carr-Hill formula, which includes patients’ age, gender and health conditions. Two practices with the same count of registered patients may have very different populations with very different needs; this is partially reflected in the weighted patient numbers. These practices, while apparently similar in terms of list size, may thus receive very different levels of funding.
The data includes all GP practices, Walk-in Centres and (combined) Walk-in Centres and Out-of-Hours practices that received a payment through the NHAIS or ISFE systems between 1 April and 31 March. Any practices which have received total payments between £-1.00 and £1.00 have been removed from the data.
Walk-in Centres may have low numbers of registered patients but apparently receive large amounts as they deliver a variety of services.
Some practices may provide a broader range of healthcare services than others, for example undertaking diabetic retinal screening for patients across the wider community rather than solely their own patient base; such practices are likely, therefore, to receive additional funding.
Prescribing and dispensing
Dispensing practices have two distinct roles for which they receive appropriate payments on both the clinical and dispensing elements of their services to patients. This should be considered when comparing them with non-dispensing practices, which rely on community pharmacies to provide dispensing services for their patients.
Regardless of their dispensing status, all practices receive fees for any personally-administered items such as vaccines and inoculations.
Prescribing costs have been categorised as Prescribing Fee Payments, Dispensing Fee Payments and Reimbursement of Drugs Payments.
PMS practices, however, may capture additional payments over and above their core services which are recorded in "Balance of PMS expenditure". These “Balance” payments could include figures relating to prescribing costs but cannot be further broken down.