Introduction

1. Following changes to the GP contract in 2025/26, GP practices are now required to work collaboratively with commissioners to implement out of area registration.

2. This change is to provide safeguards when GP practice patient lists are expanding rapidly with the registration of out of area patients.

3. This guidance supports commissioners develop and implement local policy and procedures for when GP practices need to seek their approval for operating out of area registration at scale to enable oversight of the safety and effectiveness of the arrangements for patients.

Context

4. With advances and innovations in the ability for patients to access routine primary medical services remotely there are increasing numbers of GP practices adopting operating models that utilise provisions available to register patients from outside the practice area. This has seen some GP practices rapidly and significantly grow their patient lists.

5. Whilst this innovation is to be supported where it offers convenient, clinically appropriate, access to high quality services for patients who live out of area; commissioners remain responsible for the quality, safety and performance of services who will need additional assurances particularly during periods of rapid expansion or delivery at scale where concerns can be heightened. These concerns may include:

• clinical governance
• workforce, training and clinical oversight
• safeguarding
• access to the full range of primary medical services including all screening programmes, vaccinations and immunisations, minor surgery services (3Cs) etc
• quality and outcomes, for example, participation in long-term condition reviews etc
• proximity of out of area patients to practice catchment area and the geography the local commissioner is responsible for
• financial considerations
• primary care network (PCN) considerations, for example, access to services delivered by PCNs
• sub-contracting arrangements and requirements, including:
  • ensuring sub-contracting arrangements with providers of digital tools are not giving rise to unintended consequences from the process which may disadvantage other providers
  • not setting up sub-contracts for clinical services without commissioner approval
• availability of end-to end care pathways accessed on referral or self-referral, for example, community health services including access to nursing services, midwifery services, mental health services etc
• use of other services, for example, number of calls to 111 providers in core hours/number of emergency department attendances in hours
• patient satisfaction
• ongoing review of the appropriateness of individual patients out of area registration when their circumstances change, including:
  • clinical appropriateness, for example, consideration of any patient consulting at least 4 times in any 12-month period triggering a review if the patient should register with a practice closer to home
  • practical reasons that may not support patients continued out of area registration, for example, patient travel distances within reasonable limits to attend face-to-face appointments whether from home or as commuter to or near the practice area and changes here.

Further details on this review process are given in background section of this guidance.

Background to out of area policy

6. Since 5 January 2015 all GP practices have been able to register new patients who live outside the practice area without any obligation to provide home visits or services out of hours when the patient is unable to attend their registered practice. The main guidance supporting the implementation of these arrangements for commissioners and practices is available on the NHS England website.

7. This latest guidance supplements and where applicable supersedes the main guidance.

What the GP contract changes mean

8. GP contract regulations were amended on 21 July 2025 to require GP practices to seek approval from NHS England before accepting patients residing outside their practice area, where NHS England has set out circumstances where such approval is required and those circumstances apply. A copy of the amended regulations is available on the gov.uk website.

9. With commissioning responsibility for primary medical services delegated from NHS England to integrated care boards (ICBs), ICBs (the ‘commissioner’) will now need to determine the circumstances where they require practices to seek their approval before accepting out of area registered patients.

10. ICBs being able to determine the threshold or trigger for approval recognises they are best placed to understand the status and appetite for out of area registration expansion among their GP practices. Commissioners should consult with their local medical committee on the circumstances for approval being required.

11. At the point where approval is required, a practice’s patient list should be closed to new out of area registrations until the commissioner is assured of the arrangements the practice has in place and confirms its decision to the practice. Under the amending regulations, practices accepting out of area registrations where approval is required but not yet given would technically be in breach of their contract.

12. In making the decision on the continued registration of out of area patients the commissioner should always seek to enable and maintain patient choice of GP practice.

Outline policy

Scope for requiring and triggering commissioner approval

13. Examples of the circumstances where commissioner approval may be required are provided below.

14. These circumstances may not apply to all ICBs when practices are not registering (or intending to register) patients out of area at scale. It is not mandatory for commissioners to set out a local policy for when approval is required. However, any commissioner who chooses not to implement a policy on where approval is required (for example, because of current low levels of out of area registration) should keep the position under regular review.

15. Commissioners should identify and contact GP practices to share any local policy of assigning set thresholds.

Scope

Practices already operating and progressing out of area registrations at scale.

Measure/thresholds

Percent of out of area registrations above the ICB average.  

Practices in the top decile for out of area registrations.

Scope

Practices newly operating and progressing out of area registration towards at scale.

Measure/thresholds

Percentage increase in the out of area registrations above the ICB average increase in the last month/quarter/year.

Scope

Practices planning to change their operating model to rapidly grow their registered list through out of area registration.

Measure/thresholds

Nil. The commissioner’s local policy will want to encourage practices to collaborate with them proactively on their plans prior to implementing any significant changes and supporting assurance upstream (such practices might be excluded from need to seek future approvals at any other trigger points specified locally or simply provide a review touch point at those points).

Determining local set thresholds 

16. Business intelligence to support determining local set thresholds is currently available to commissioners through the Primary Care Registration Management (PCRM) self-service. Reports accessed via smartcards include:

• GP practice of choice: this report provides a list of patients that are flagged as ‘out of area’ for their respective GP practice and are therefore excluded from payment calculations adjustments which compensate for patient rurality. Practice of choice is the term used for the flag with PCRM and this is normally declared by the GP practice when registering the patient.
• GP practice patient distribution: this report details the geographical distribution of patients registered with a specified GP practice or practices to allow commissioners to understand the challenges of a particular GP practice more fully.
• GP practice capitation: an ad hoc capitation report for selected GP practices to identifying how many patients the GP practice or practices have registered at the end of each quarter.
• GP practice patient registrations: an ad hoc report identifying patients who have registered with a specified GP practice, including the reason for registering. This allows commissioners to understand, for their locality, how many patients are registering for a GP practice and why.

17. Local contextual factors may also apply, for example, any other providers of large scale out of area providers.

18. NHS England is exploring capability to routinely provide these reports on a quarterly basis to commissioners and to including relevant enhanced reporting in existing reports, for example, capitation reports.

GP practices currently operating out of area registration at scale

19. Commissioners should prioritise assurance for any GP practices currently operating out of area registration at scale.

20. For these practices, commissioners may wish to consider the position on whether they will exceptionally continue to allow new out of area registrations whilst this assurance is obtained, for example, because there are no clear patient safety or quality concerns or considerations. Otherwise, the default will be from the point of communicating the local policy that approval is required, the practice’s patient list should be closed to new out of area patient registrations until assurance (approval) is gained.

Assurance process and checklist

21. The assurance process should be proportionate and undertaken ideally within a 28-day period of receiving the necessary information from the GP practice, including any supporting recommendations to be made as a condition of continuing out of area registration.

22. What is proportionate in any particular case will depend upon the circumstances and the commissioner’s assessment of the potential risks associated with the proposal.

23. A template assurance checklist is provided in annex A, which commissioners may wish to use (this is not mandatory). This checklist is broken down into 3 parts:

i. Out of area registration plans – essential information that will be required to describe and understand the scope of the out of area registration intentions relative to current operating arrangements.

ii. Practice policies and procedures – the practice is able to evidence through its current or proposed policies and procedures the safe and effective operation of out of area registration.

iii. Assurance areas – this is a list of areas where the commissioner will want to be assured of which could feasibly present a risks or issues in operating out of area registration at scale.

24. Commissioners should follow similar protocols applied to contract variation requests when confirming receipt of a practice application, timetable for decision, approvals and any appeals.

Next steps

25. Commissioners should:

• assess the need for a local out of area registration policy that sets out when approval is required
• where such a need is identified, develop their policy, consulting with their LMCs
• notify all GP practices of their local out of area registration policy, including notifying directly any practices immediately in scope of needing approval where appropriate. This policy may only be implemented following notification of the agreed contract changes in 2025/26, ie earliest effective implementation from 1 September 2025
• have systems and processes in place to monitor (for example, as they do for capitation) status of practice out of area registrations on a quarterly basis which may trigger requirements for approval

26. GP practices should:

• monitor their out of area registrations in line with any local commissioner policy
• where in scope of local commissioner policy trigger, stop ongoing out of area registrations by changing their status in NHS profile manager to no longer accepting out of area registrations (to halt out of area registrations occurring in patient online registration services)
• work with their local commissioner to provide such information as requested to support approval for continued out of area registrations

27. Commissioners should prioritise assurance applications for current large scale out of area providers.

Publication reference: PRN01498