Reluctance of general practice staff to register patients without documentation: a qualitative study in North East London.

Abstract

Lack of access to documentation is a key barrier to GP registration, despite NHS England guidance stating that documents are not required. Staff attitudes and practice regarding registration of those without documentation are under- researched. To understand the processes through which registration might be refused for those without documents, and the factors operating to influence this. Qualitative study conducted in general practice across three clinical commissioning groups in North East London. In total, 33 participants (GP staff involved in registering new patients) were recruited through email invitation. Semi-structured interviews and focus groups were conducted. Data were analysed using Braun and Clarke's reflexive thematic analysis. Two social theories informed this analysis: Lipsky's street-level bureaucracy and Bourdieu's theory of practice. Despite good knowledge of guidance, most participants expressed reluctance to register those without documentation, often introducing additional hurdles or requirements in their everyday practice. Two explanatory themes were generated: that those without documents were perceived as burdensome, and/or that moral judgements were made about their deservedness to finite resources. Participants described a context of high workload and insufficient funding. Some felt that GP services should be restricted by immigration status, as is widespread in secondary care. Improving inclusive registration practice requires addressing staff concerns, supporting navigation of high workloads, tackling financial disincentives to registering transient groups, and challenging narratives that undocumented migrants represent a 'threat' to NHS resources. Furthermore, it is imperative to acknowledge and address upstream drivers, in this instance the Hostile Environment.