From: Farrelly George
Sent: 14 May 2011 12:38
Subject: King’s Fund position on GP Practice Boundaries?
Dear King’s Fund,
I am a GP in Tower Hamlets. I have a particular concern about the proposal to abolish GP practice boundaries and allow patients to register with the practice of their choice, anywhere in England. When my wife and I were interviewed in 1991 to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ on the list. At that time it was regarded as bad practice to have people living at a distance from the practice, and good practice to have a practice population which was close to the practice. In 20 years of practice, in a myriad of ways and on a daily basis, I have seen the difficulties that occur when patients move away and continue to use us as their GPs. Managing people’s healthcare when they live at a distance is more difficult for the practice, more difficult for the patient, and leads to situations that are sometimes unsafe. I am bewildered when I hear politicians and DH people say that practice boundaries are ‘outmoded’, ‘old fashioned’, ‘anachronistic’.
In his closing remarks after a speech by Andy Burnham at the King’s Fund on 17 September 2009, your then CEO said this:
On the plan to make it easier for patients to choose their GP, Niall Dickson said: ‘The vast majority of patients are more than happy with their GP, but the restriction on where they can register is an anachronism and the government is right to sweep it away. There are details to be worked out, but it should not be impossible.’
The King’s Fund says that it ‘seeks to understand how the health system in England can be improved.’ Can you tell me what the King’s Fund thinks at present on this issue of GP practice boundaries (or practice areas as they are also called)? Would abolishing them improve the health system in England? If yes, then explain how.
I have included this email on my blog, see http://bit.ly/loE7uN
The Tredegar Practice
From: Beccy Ashton [King’s Fund]
Sent: 26 May 2011 17:03
To: George Farrelly
Subject: GP boundary inquiry – final response
Dear Dr Farrelly,
Thank you for your emails which have been passed to me for a response and please accept my apologies for the delay in responding.
As you mention, it was our previous Chief Executive who made the statement to which you referred. Our recent inquiry into the quality of general practice did not look in detail at this issue but I have consulted with colleagues about our current position. We are in favour of the right of patients to choose a GP practice, enshrined in the NHS constitution. It is clear that the coalition government is aiming to increase rather than to restrict patient choice in all areas of health care though as our recent report on patient choice notes, there has not been much focus on increasing choice in primary care. The majority of patients will choose easy access to a practice close to home, but for example there may be some patients who need regular non urgent contact with a GP who would find it more convenient to see a GP near their workplace.
Our current contribution to the coalition government’s listening exercise on the bill considers the GP commissioners’ role and stresses that as far as possible GP commissioning boundaries should be aligned to geographical and local authority boundaries in order to address population health issues including tackling health inequalities, promoting public health and serving the needs of hard-to-reach groups. However, individual practices may not necessarily require a geographical footprint.
In short, we are not in principle against the idea of allowing patients to register with GPs other than in their local area though clearly there are issues that would need to be worked through to ensure the benefits of local registration are not lost.
Adviser to the Chief Executive, The King’s Fund
From: Farrelly George
Sent: 3/6/11; 09:29
To: Beccy Ashton, King’s Fund
Subject: King’s Fund position on GP Practice Boundaries?; further clarification
Dear Beccy Ashton,
Thank you for your reply to my email on the GP boundary issue. In my email I asked 2 questions: 1. what is the King’s Fund position on the issue of GP practice boundaries, should they be abolished (an anachronism, to be swept away, your previous CEO said)?; 2. Would abolishing them improve the health system in England? If yes, then explain how.
You have answered my first question, though in quite an abstract way. First you say you ‘are in favour of the right of patients to choose a GP practice, enshrined in the NHS constitution’. You then say that the majority of patients will choose easy access to a practice close to home, ‘but for example there may be some patients who need regular non urgent contact with a GP who would find it more convenient to see a GP near their workplace’. The next paragraph is a bit tangential. You then close by saying, ‘In short, we are not in principle against the idea of allowing patients to register with GPs other than in their local area though clearly there are issues that would need to be worked through to ensure the benefits of local registration are not lost.’
You have not answered my second question, which is in essence this: what effect will abolishing GP practice boundaries have on the system? The King’s Fund says its prime aim is ‘to seek to understand how the health system in England can be improved’. This, I agree, is a very important aim, and I am glad that there are people trying to do that. It’s just that in this case I think you (and the Department of Health, and Andy Burnham, and Andrew Lansley, and the three major political parties, so you are in good company) have got yourselves into a muddle. I say this because our practice has in essence been carrying out a de facto pilot on this issue for the past 20 years: what happens to the health system of one GP practice if patients live at a distance from the practice? And we have found it if fraught with numerous problems, leading to poor care for the patient (in some cases with serious consequences), and imposing significant additional demands on limited practice resources. Sure, there are some organised individuals who can pull it off (until they get sick), but as a whole, systemically, it is very problematic.
The difficulty seems to be that you do not actually model your idea (nor does the DoH, nor the ministers). Normally, of course you would. This is presumably what think tanks do: think of all the issues, how the thing will work overall, and so on. In this area of ‘choice’, modelling has been forgotten. It’s as though it is the National Choice Service and not the National Health Service.
Let me give a concrete example: with respect to obstetric care, St Thomas’ Hospital have had a good reputation for many years. We have middle class patients who have done their homework and ask to be referred to St Thomas’ for their antenatal care. Now the response has been that St Thomas’ is unable to accept the referral because they have exceeded their capacity and are only able to accept referrals from within their catchment area. Now this seems to me to be a perfectly sensible stance on the part of this unit. Were they to exceed their capacity, the quality of their service would deteriorate and and risks would increase. So choice in this case is constrained. Now other secondary care units do not have this option to refuse to accept a referral: if a referral arrives, they have to find a way somehow to see the patient, and within a certain time frame. If their capacity is exceeded they have to find a way of increasing their capacity (by hiring locums commonly), and the quality of the service declines (we see this all the time).
In the case of primary care and practice boundaries, the levels of complexity are far greater, the ‘system’ is more complex, the knock on effects more numerous. What Andrew Lansley (and before him Andy Burnham) is proposing is not to find a way for the banker to register with a practice near his place of work (and in this case I can see an argument for finding some solution), but for people to be able to register with a practice ‘anywhere in England’. We have people who would ‘choose’ to remain registered with us though they live on the other side of London and their place of work is nowhere near us.
For concrete, everyday examples of the undesirable consequences of patients living at a distance from the practice, see this.
Now another area that requires modelling is this: I decide to register with a practice 5 miles away (or 20 miles or 100 miles) because I have heard that Dr Smith is a great GP. The difficulty is that Dr Smith is currently working full time, he has no more capacity. Sure, his practice can expand a bit, get some additional GPs in, but you will not be seeing Dr Smith. Or if you do see Dr Smith, it will be at the expense of some other patient who cannot get in to see Dr Smith. So the whole thing is really a mirage.
So I repeat my question to the King’s Fund: will abolishing GP boundaries in England improve the health system? If yes, please show how; and show also that you understand how the system works as a whole, and how you are going to deal with the unintended consequences.
Now I don’t really expect you or your colleagues to address this, because you are busy and this is unfunded work. And also because it is a hellish question to answer if you try to do it within the constraints of the real, concrete world.
It is puzzling how presumably clever people can be so myopic about this issue. I mentioned this to an experienced GP colleague from Hackney recently. She said, ‘They’re not stupid. What they are aiming for is opening things up for HMO’s.’
I really hope that the King’s Fund thinks honestly about this issue and really does get to grips with finding ways of improving the overall quality of the system in England.
[if there is further correspondence, it will be added]
[…] Here is a letter he sent to King’s fund about the matter. […]
I’m afraid that your friend was right; that this is about opening the way for HMOs. Patient choice cuts both ways. If a patient does not need to register with the nearest GP, then the GP does not need to register those nearest him. This means that he can pick and choose his patients and if he has to make a profit for a company, he’ll pick the patients that are well and leave the ones that are sick. People that are elderly, chronically ill or disabled won’t have a look in. Good email btw.