What is the point of practice boundaries?

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

Every GP practice in England needs to save £2,500 a day over the next three years to hit NHS efficiency targets, according to a senior DoH adviser

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 17.1.2012

A GP writes about her experience of caring for a patient outside her practice boundary