The government is proposing to abandon practice boundaries. To do so will destroy personal care, destablise practices and pose great risks to patients.
Almost every new patient that registers with me asks the question, “Are you going to be my GP?”
Its not just the young American woman with cancer, the elderly man who has had a stroke, the couple expecting their first baby or the postman with depression. The overwhelming majority of people still want a doctor who knows them, their medical history and their personal story. This personal care and relationship between patients and doctors is the heart of general practice in this country, and in-spite of all the changes that have undermined this in the last 20 years or so, it remains universally popular.
Practice boundaries exist so that GPs can make a committment to, and take responsibility for a population within a specified geographical area. If you are sick they commit to take care of you and that care extends to your home. Practice boundaries guarantee that your own personal doctor can visit you in your own home when you’re too sick to get to the surgery and that you can see a GP close to where you live. If practice boundaries are removed and our patients come from miles away, their home care will have to be provided by doctors or nurses they do not know, or you may find that you have to travel further to register with a GP.
Young, mobile patients who consult infrequently generate income for GP’s because the fee we earn from registering them exceeds the cost of care. It is because of our patients who need little care that we can look after patients who need a lot of care. If young patients who want a quick, convenient service choose to register with a Virgin or Sainsubury’s surgery because it’s quick and convenient, then established practices will be left with increasingly complex and costly patients and they will soon be bankrupt.
Suburban practices will be particularly worried about the changes because their commuter patients will register in the cities, leaving them with the elderly, housebound, the unemployed, young mums and children. All of whom consult more and have greater health needs that average.
There is a dark side to the changes that the government should pay close attention to. Child abuse is high on the media and political agenda. If practice boundaries are removed then child abusers will make sure that their children are registered at different practices. At our weekly meetings with the health visitors we will no longer have the level of knowledge about families we have at present. No amount of government meddling with IT can make up for this.
Every practice that cares about their patients and every patient that cares about continuity of care with their own doctor should strongly protest about this absurd proposal.
See also Iona Heath, The Perversion of Choice,
your freedom to choose any practice, qualifiesmy freedom to choose continuity of care when I am old and frail.The age old conflict between liberty and justice lives on wheneverchoice is exercised, in the NHS as elsewhere, and it is bothnaive and futile to pretend that it could ever be otherwise.
Update: 26.01.2011
The easiest way to save this amount of money is to stop looking after anybody who is really sick. Last year one of my patients, a young man with epilepsy and Crohn’s colitis had to go into hospital to have his abdominal wall repaired. For the third time. After emergency surgery to remove large amounts of his bowel he was left with a colostomy. When this was repaired the wall of his abdomen: the muscle, skin and connective tissue, refused to heal. He spent several weeks in hospital following an infection which caused the wound to break down and then came to see our practice nurse twice weekly for dressing changes for several months before eventually being referred for an experimental treatment involving a large graft. He was very sick after the graft operation and spent several weeks in hospital including time on the ICU. Six months on his wound has still not healed. He has become depressed and his epilepsy has deteriorated and so he is seeing the psychologist and the neurologist.
Because of the purchaser-provider split we pay for all the care he gets in hospitals and for all the specialist referrals. At present the cost is paid by the PCT and they tell us what our costs are as a practice.
Once we have our own budget, someone like this will knock an enormous hole in our finances. If we could find a way of getting him, and a few other patients with similarly complex medical needs to register somewhere else, we might, just, be able to get near the £2500 a day ‘efficiency savings’ demanded by the Department of Health.
We’re not going to do this. And I don’t know of any GPs who would consider doing such a thing. But until now GPs haven’t had the threat of insolvency hanging over them just for doing what they are trained to do, looking after people who really need it.
We still have the absurd situation described by the Inverse Care Law where those GPs who work in areas with the least health needs i.e. the wealthiest areas, earn the most money for the least work. The Inverse Care Law states that The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.
Update 19.11.2013
Any GP you want, so long as you’re healthy. Jeremy Hunt wants to scrap GPs’ catchment areas to give patients more choice. Sounds great – until you think it through. Guardian CIF
17.1.2012
A GP writes about her experience of caring for a patient outside her practice boundary
A Better NHS 
Thank you for telling it like it is. I had not even considered some of the points you make and I’m sure most people won’t have either.
What would your plan for the NHS be?
An excellent article. The child-protection issue is one that hadn’t occurred to me but is indeed very worrying.
I met Andrew Lansley ~18 months ago when he visited the hospital I then worked in. I regret not kicking him in the shins.
I am torn between thinking Lansley is blind and stupid or thinking he is very clever and malevolent. Not that it really matters but please can we find a way to stop these evil reforms.
AFZ
I agree that there are some important points here. I had never thought of the child protection issues for example. But that seems to me one that can’t be solved by practice boundaries alone – in many urban centers a family may be covered by multiple practices and the same could occur. But I know little of the best way to address child protection issues, so I shan’t comment on that further.
My greater issue is that restricting registration geographically limits patients in ways that also have unintended consequences. I make no bones about my opposition to practice boundaries and restricted choice being influenced highly by my own experiences. But I also think there are some larger concerns on which my own experiences can shed some light. My own experience as someone who, living in the private rented sector, has very low levels of security of tenancy is that practice boundaries have led to a worse level of care. I am young(ish) and I require continual care; this makes me perhaps atypical, I don’t know. I see GPs at least 12 times a year. The quality of my relationship with GPs is important to me – a point you cite in defence of practice boundaries. But because I am often made to move – typically I become priced out of my accommodation as rents increase – I have no continuity of care. Until recently, I maintained my relationship with my GP by lying about the fact that I hadn’t moved. This worked for a while, until I needed greater levels of care that would have meant having to reveal to the practice that I had long since lived outwith their boundary. So I had to move practices after three years and having found the best, most supportive GP I have ever had. In contrast to the item you cite about open practice boundaries compromising one’s quality of care, closed boundaries can also lead to a compromised quality of care. There are potentially winners and loses under any system. The current system is inflexible and sub-optimal for me. For others inflexibility may be helpful. I consider it to be a way of limiting my autonomy as a patient. I experience poor quality of care at the moment because I am not free to choose who provides that care.
Part of the problem seems to arise from the ways in which GPs receive their income. To be paid the same for all patients irrespective of their needs is inefficient and unfair. Unfair to the patients who might choose a GP further from home, such as myself. And unfair to GPs who have to manage a patient list through cross-subsidies from the healthy to the ill, which gives rise to unintended and perverse consequences. The problem it seems to me is administrative – how to get the money to practices to support patients based on need. This would mean that a commuter practice would get paid to do high volume low need work, and a ‘local’ practice would be funded appropriately given the higher need patients. To eliminate practice boundaries may have the consequences you describe without concomitant changes in funding arrangements. But that isn’t the fault of boundaries, but the funding system.
One thing I can see as opposition to my point of view is that, as someone who moves a lot I may be atypical. I am not atypical among the people I know though (of course, that is a very narrow section of society, but that doesn’t mean our views don’t count).But even at the population level people move a lot, especially in urban areas. In many cases they will be happy to move GP practices, in others not. Fix the funding arrangements, and for the opposition to open boundaries falls away.
As a GP with a few young patients who have moved out of area, but have complex/ ongoing health needs and appreciate continuity of care, who I have allowed to remain on my list, I sympathise with your predicament, and since I don’t get paid for looking after them because they don’t live in Hackney – I agree that the funding is a part of the problem. I’m not sure that the problem falls away with a funding fix, as I think we need to ensure that patients who move to Hoxton are not prevented from registering with our practice because we are full of patients who no longer live in Hoxton, but don’t want to change GP -there are a lot of them, and barely a day goes by without someone complaining or we find that they have been lying about their address. We have about a 30% list turnover (3-4000 patients a year) so it might not take long to fill our books with patients who no longer live locally, whilst local residents have to look further afield for care. I have my own list of about 1400 patients and cannot expand endlessly, that is about the maximum I can manage. Being able to walk to your GP is pretty essential for many of our older patients, or mothers with young children, or disabled patients. I’ve had to refuse to keep elderly patients on my list who I have known for years, because I cannot commit to the time involved in traveling to them for home visits, but the young people with chronic illnesses who are able to get themselves to the surgery are allowed to stay, and I feel uncomfortable with that.
My main concern, I think, is my (perhaps naive) belief that nobody should have to suffer bad healthcare, and more must be done to improve poor care than simply allow (or even actively encourage) people to move to a new GP, for the simple reason that there will always be those who are too vulnerable / frail/ confused etc. to change, and they need the best care, not the worst. Fortunately GPs are finally waking up to the fact that they must federate and take more responsibility for the behaviour and quality of their neighbours and if we are not massively rearranged again, things might finally improve. Jonathon
Thanks very much for your blog, and this post. The link at the end of this post (‘A GP writes ‘) goes to a sign-in page at the BMA; I could not log in with what I thought was the correct login; I think the story you are linking to is this one: http://onegpprotest.org/2013/05/11/why-gps-have-practice-boundaries/ ; if so, it is no longer available online; I know, because I tried to access it; I got the BMA to send it to me and I have published it on my blog.
It is interesting that the GP ‘capitation’ system of pay is so poorly understood by everyone who pays for the health service. If people understood that a GP gives unlimited care for about £80 a patient a year, and an A+E visit – especially zero day admission can cost up to £2,000 – they’d understand why no one wants to pay GP per visit . ‘Funding fixes’ would be extremely complicated to construct and expensive.
I suspect that a market committed government is developing a two tier system – a private provider delivered ‘well being center’ staffed by sessional doctors much like medicenter – doling out inappropriate antibiotics, sleeping pills and anything demanded by its upmarket clientelle to be rated as ‘excellent customer focused staff’. ‘List based’ / boundaried General Practice will be expected to deal with the complex, frail elderly housbound or economically disadvantaged population. This work needs more than the ’10 minute consultation’. I agree that developing multi disciplinary teams with skills that contribute to this will need more federation and skill sharing – What is key is that the federating is done in an equitable, inclusive and geographically based way – and without going borough wide risks an even more pronounced inverse care law.
to add – the minimum cost of one A+E visit ‘seen but no treatment given’ is £66 at our local hospital