The following are some examples to illustrate why registering with a GP at a distance has its problems. These examples are all within the past 6 weeks.
1. A man in his late twenties consulted one evening. At the end of the consultation, having dealt with 3 separate health issues which he said he ‘had saved up’, it emerged that he had moved to south west London. I said he would have to get a local GP; he was reluctant: left to his choice, he would have opted to remain our patient. I pointed out that in order to see me he had to travel more than an hour each way. If he were unwell, what would he do? He said he worked in King’s Cross (about 30 minutes by underground, if there are no delays). But to see me he would have to travel 30 minutes further away from his home, and then over an hour to get home. Was this going to favour him seeing me when appropriate? He agreed that this probably was not a good idea.
People in this situation ‘save things up’ because they want to get it all done at once. The trouble with this is that it greatly crowds the 10 minutes we have; the quality of the consultation is lowered as it is hurried, we over-run and so the surgery is then running late which affects others.
2. Patient L is in his/her 50’s. L has been a patient of our’s for years. L moved out of our area, about 2 miles away (15-20 mins each way), some years ago. L was removed from the list, but re-registered at a local address. We subsequently found out L was not living there. L was removed from the list last November but continued to come for repeats but did not register with a local GP. L became unwell in December; L had appointments to see us but did not attend because L’s problem meant that L felt unable to leave home. It was not possible to make a diagnosis over the phone; L needed to be seen in person. Had L lived in our area, we would have visited. L attended A+E on two occasions; on the second occasion, L was admitted with a serious condition, and also an underlying cancer.
We provided prescriptions after discharge (though not registered with us), and did our best to get L registered with a local practice.
[6.8.11: This patient has since died.]
This experience has made us more determined to insist our patients get registered with a local GP: for their welfare.
3. Patient Q had surgery and needed daily dressings. Q’s address was near the surgery (less than 1 minute), but Q had moved 2 miles away, into a neighbouring borough (15 minutes each way by car, unless traffic). Our district nurses visit patients within our patch. They are overstretched as it is, and do not have the resources to see patients in neighbouring boroughs. Had Q been at Q’s registered address, Q might have been able to see our practice nurse, or have a district nurse visit. Instead, Q travelled to the hospital A+E to have it changed; quite an inappropriate model for care, and costly.
4. Patient F recently had major surgery. When discharged from hospital, F went to stay with relatives about 2 miles away (travel time to surgery 15-20 mins each way by car). F probably had a wound infection; I diagnosed this over the phone. I would have preferred to have seen F, but cannot afford to go visiting as time does not permit. Not a desirable model of care.
5. The A family, two parents, three children, moved out of the area, 5 miles away in a different borough. Mrs A has chronic diseases with reduced mobility, and hardly gets out. In recent years, most contact had to be on home visits (5 minute walk). Various services were in place for Mrs A; these services are run for borough residents and do not extend to where they live now. Left to their decision, the A family would have opted to stay with us. This would have led to disastrous care, a model of how not to do it. We had to insist they get a local doctor and in the end had to remove them.
6. Patient S is in his/her 50’s and lives alone; S has a chronic neurological condition which reduces S’s mobility. S was rehoused about 2.5 miles away (travel distance for me 15-20 minutes each way by car). At the moment S is able to manage public transport and wants to remain our patient. I sympathise with S’s request; but I explain that if S becomes unwell, the GP needs to be able to get to S’s home easily. ‘That’s ok, doctor, I will call an ambulance,’ S says. I explain this would not be appropriate. I liaise with a practice local to S and he/she should be able to register with them. I assure S that if S moves back to our area, we will re-register S immediately, without delay.
These are all examples from the past 6 weeks. In each case, distance is a very real barrier to care. In some cases, this barrier makes things unsafe. In all cases it leads to inefficiency and corners being cut. At a time when we are being asked to make efficiency savings, this government wants to introduce a policy that, in its very design, will increase inefficiency considerably and in some cases be unsafe.
I have only listed here examples of patients who have moved a relatively short distance outside our practice area. On the face of it, you might think this would not make much difference. In reality, it does make an enormous difference.
Oh, it has occurred to me to mention 2 instances which highlight in a positive vein what goes right when patients live nearby. Both examples are from last week.
Patient T has a serious mental illness. Patient T came to the surgery seeking help (3 minute walk); T was assessed. My colleague spoke with the relevant mental health team and arranged an urgent assessment at home; T returned to the surgery again and saw my colleague; the community team came to the surgery to give my colleague the necessary papers to sign; the patient was admitted to hospital. This could not have happened if the patient lived 2 or 3 miles from the practice.
Patient R is receiving palliative care at home and is in the terminal phases. I visited the home 3 times last Friday (less than 2 minutes walk). Family members came to the surgery at one point to seek help (less than 2 minute walk). This meant that things were put in place to maximise care for the weekend. This could not have happened if the patient lived 2-3 miles from the practice.
Politicians, please take note. Please engage critical faculties. Do you want choice or do you want quality?
Your descriptions are similar to our own experiences (distances and traffic different from inner London), and we also operate a practice boundary policy because to do otherwise would be dangerous for the sorts of reasons you cite. Over-stretching, under capacity reduces quality of care, sometimes with the disastrous results that you describe.