NHS England is undertaking what the BMA describes as an “aggressive” patient list cleansing exercise across the country.  According to some reports this has resulted in the removal of 450,000 patients from practice lists since November last year.

This list cleansing is clearly part of an NHS England cost saving plan.  It is no secret that the NHS is struggling to balance its books, and despite calls for any money generated by this exercise to be reinvested in general practice it is no surprise that these have fallen on deaf ears.

Most NHS cost saving or cost recovery plans try and find ways of reducing expenditure without making changes to how things work.  Rather than innovate to reduce costs, the NHS will more commonly try and find ways of reducing what it spends without changing anything.

A good example is how it has used capital funding to resolve revenue gaps.  It feels like a clever accounting trick that enables them to balance the books, but what it has actually resulted in is a crumbling and aging estate that is no longer fit for purpose.

Another example is high-cost care packages for patients.  Here the aim of the exercise is to reduce the amount the NHS pays for these packages.  The main outcome of this is that others, mainly social care but sometimes individual families, are left instead with the financial burden.

List cleansing is the same.  There is no change in the service provided, but the NHS ends up paying less for it.

NHS England justifies list cleansing by saying that they are ensuring value for taxpayer money by not paying for patients that do not exist.  But in reality it is an abuse of the population-based funding model.

General practice funding is population based.  Practices receive a weighted sum for every patient on their list.  This sum is regardless of the amount of activity generated by any individual patient.  The model has worked because even though the funding per patient is insufficient to cover the costs of the relatively small percentage of patients that generate the majority of work for practices, this is offset by the funding received for the majority of patients that generate relatively little work for practices.

The problem with list cleansing is that it skews this model.  Not only does it reduce the total amount of income that practices receive, it removes it with little or no reduction in activity (because by definition it is removing patients that have not been active with the practice).  Adding insult to injury, the process itself generates additional work for practices.

If you consider this in the context of the (unfunded) additional demands placed on practices to provide same day responses to urgent requests and operate systems that do not cap online submissions, then the problem of the population-based funding model is simply exacerbated.

If general practice was operating an activity-based funding model you can guarantee NHS England would not be carrying out the list-cleansing exercise, and would have thought twice about the urgent care changes because of the price tag it would have brought with it.

If NHS England continues to abuse the population-based funding model, something will have to give, and at present that is most likely practices being unable to continue.  While the main argument against list cleansing appears to be the impact it can have on vulnerable patients groups (that I haven’t even covered here), it also presents a very real threat to the viability of the way that general practice is funded.