On BBC Radio 4 the other day, I heard that people who have not been to see their local GP in the last 5 years could face being ‘struck-off’ from the register and denied access until they re-register – the story is also covered in most of the national press, including The Guardian. It’s an effort to save money on NHS England’s £9bn annual expenditure on GP practices, but is it the most cost-effective and patient-friendly approach for updating NHS records?
Under the contract, an NHS supplier (Capita) will write every year to all patients who have not been in to see their local doctor or practice nurse in the last five years. This is aimed at removing those who have moved away or died – every name on the register costs the NHS on average around £136 (as at 2013/14) in payments to the GP. After Capita receives the list of names from the GP practice, they’ll send out two letters, the first within ten working days and the next within six months. If they get no reply, the person will be removed from the list. Of course, as well as those who have moved away or died, this will end up removing healthy people who have not seen the GP and don’t respond to either letter. An investigation in 2013 by Pulse, the magazine for GP’s, revealed that “over half of patients removed from practice lists in trials in some areas have been forced to re-register with their practice, with GP’s often blamed for the administrative error. PCTs (Primary Care Trusts) are scrambling to hit the Government’s target of removing 2.5 million patients from practice lists, often targeting the most vulnerable patients, including those with learning disabilities, the very elderly and children.” According to Pulse, the average proportion that were forced to re-register was 9.8%.
This problem of so-called ‘ghost patients’ falsely inflating GP patient lists, and therefore practice incomes, has been an issue for NHS primary care management since at least the 1990’s, and probably long before that. What has almost certainly increased over the last twenty years is the number of temporary residents (e.g. from the rest of the EU) who are very difficult to track.
A spokesperson for the BMA on the radio was quite eloquent on why the NHS scheme was badly flawed, but had no effective answer when the interviewer asked what alternatives there were – that’s what I want to examine here, an analytical approach to a typical Data Quality challenge.
First, what do we know about the current systems? There is a single UK NHS number database, against which all GP practice database registers are automatically reconciled on a regular basis, so that transfers when people move and register with a new GP are well handled. Registered deaths, people imprisoned and those enlisting in the armed forces are also regularly reconciled. Extensive efforts are made to manage common issues such as naming conventions in different cultures, misspelling, etc. but it’s not clear how effective these are.
But if the GP databases are reconciled against the national NHS number database regularly, how is it that according to the Daily Mail “latest figures from the Health and Social Care Information Centre show there are 57.6 million patients registered with a GP in England compared to a population of 55.1 million”? There will be a small proportion of this excess due to inadequacies in matching algorithms or incorrect data being provided, but given that registering a death and registering at a new GP both require provision of the NHS number, any inadequacies here aren’t likely to cause many of the excess registrations. It seems likely that the two major causes are:
- People who have moved out of the area and not yet registered with a new practice.
- As mentioned above, temporary residents with NHS numbers that have left the country.
To Data Quality professionals, the obvious solution for the first cause is to use specialist list cleansing software and services to identify people who are known to have moved, using readily available data from Royal Mail, Equifax and other companies. This is how many commercial organisations keep their databases up to date and it is far more targeted than writing to every “ghost patient” at their registered address and relying on them to reply. New addresses can be provided for a large proportion of movers so their letters can be addressed accordingly – if they have moved within the local area, their address should be updated rather than the patient be removed. Using the same methods, Capita can also screen for deaths against third party deceased lists, which will probably pick up more deceased names than the NHS system – simple trials will establish what proportion of patients are tracked to a new address, have moved without the new address being known, or have died.
Next, Capita could target the other category, the potential temporary residents from abroad, by writing to adults whose NHS number was issued in the last (say) 10 years.
The remainder of the list can be further segmented, using the targeted approach that the NHS already uses for screening or immunisation requests: for example, elderly people may have gone to live with other family members or moved into a care home, and young people may be registered at university or be sharing accommodation with friends – letters and other communications can be tailored accordingly to solicit the best response.
What remains after sending targeted letters in each category above probably represents people in a demographic that should still be registered with the practice. Further trials would establish the best approach (in terms of cost and accuracy) for this group: maybe it is cost-effective to write to them and remove non-responders, but if this resulted in only removing a small number, some of these wrongly, maybe it is not worth mailing them.
The bottom line is that well-established Data Quality practices of automatic suppression and change of address, allied with smart targeting, can reduce the costs of the exercise and will make sure that the NHS doesn’t penalise healthy people simply for… being healthy!