Your Choice of GP: the Problem in a Nutshell

All three of the main UK political parties favour the policy of people in England being able to register with any GP, regardless of where they live. At present, patients must register with a GP in the area where they live.

This idea of registering with the GP of your choice (anywhere in England!) sounds like a good idea, who would not wish it? Unfortunately, there are real problems with implementing such an idea. The way I look at it, there are 2 main problems with this proposal:

1. The first is that it will introduce additional levels of complexity which will make providing good quality general practice much more difficult in most cases with those patients living outside the practice’s area (more time consuming, less integrated, less efficient; in some cases unsafe). This will be worse when a patient is actually unwell and is unable to travel far to be assessed by their doctor. If follow-up is necessary, then the patient will need to return to see the doctor; if the journey is a lengthy one, then this is a barrier. What about tests (blood tests, xrays, scans)? Do these get done in the GP’s locality (in which case the patient may well need to return for this), or where the patient lives (in which case getting the results takes longer and is less integrated; for example, our blood test results come through electronically and are filed with a click of the mouse; not so for even neighbouring hospitals, let alone a hospital miles away: these take longer, might not arrive and then have to be phoned for, have to be entered in the patient record manually…). Who is going to pay for treatment (tests, drugs, referrals, psychology, physiotherapy)? At present, funds are allocated to a given area, a given population. If someone comes from outside that area, will his or her area of residence pay? If not, then the local health economy will have its own local (limited) resources depleted by non-residents. If the area of residence pays, then how will this be billed and paid? This is what I mean by levels of complexity. There are already very significant levels of complexity within our local health economy which make working often inefficient. If we add to this local complexity additional complexity which is beyond our control this will further tax the system. (This is just an overview, there are a myriad of complexities; see also separate post on examples of problems with patients outside practice area).

2. The problem of capacity. This will make the proposal unworkable. GPs are currently all working at capacity. There may be a few exceptions to this, but fundamentally GPs do not have spare capacity. What I mean is this: imagine you want to register with a doctor 5 miles away because a friend has said how good Dr Spencer is. It is most unlikely that Dr Spencer has spare capacity, that is to say available appointments for the patients outside her practice area. Of course, Dr Spencer’s practice can expand, and perhaps they will want to expand; but Dr Spencer herself cannot expand. She can only see so many patients. Of course, she can speed up her consultations: cut them from 10 minutes to 5 minutes. Ask Dr Spencer what she thinks of that, what she thinks that will do to quality. Ask Dr Spencer’s current patients what they think of that.

These issues are not complicated, they are not ‘rocket science’. But they are very real. The politicians do not seem to be aware of these issues, do not seem to be taking them into account. In New Labour’s consultation documents on this question there is no recognition of these difficulties. I wrote to Andrew Lansley about this in March 2010 (see link below); the reply I received made it plain that he and his team had not considered the risks of this plan.

Our practice would not be able to provide a service under these conditions. We are not able to register all the local residents who want to register. In addition, we are clear that to provide quality care for patients they need to be local to us, we need to be local to them.

You need to understand the ecology of general practice, how it ‘works’, what makes it ‘work well’. Then you will be in a position to judge whether this proposed policy will make it work better, or make it work less well, or badly.

For more on this issue:

My email exchange with ‘Andrew Lansley’

Some examples of the difficulties that arise with patients registered outside the practice boundaries

 The politicians’ and DOH planners’ methodology is faulty

The Royal College of General Practitioners’ response to the government consultation ‘Choose Your GP Practice’

My email exchange with The King’s Fund

 My email exchange with an MP

4 Responses to Your Choice of GP: the Problem in a Nutshell

  1. rofique says:

    Thanks for your blog. I agree with most of it (I have read the front page and emails to lansely in detail, the rest at a glance).

    The patients problem needs resolving: what do you do if you move to an area and cant see a GP.

  2. roseanna says:

    Good to spell it all out in crisp detail. We should keep on with best practice. If policy turns into law and a contract but there are unintended harmful consequences to the quality of patient care we should flout the badly made law and contract. Judicial review is increasingly popular. Maybe there will come a time for using that to challenge bad policies.

  3. Anoop says:

    Thank you for the blog. Removal of practice boundaries would make it much harder to provide quality GP services to the most vulnerable groups of patients.

    Local GPs generally provide a good service to elderly patients, housebound patients, patients with chronic illness, pregnant women, babies and children. These groups of people tend stay in a geographical area for a period of time, and tend not to be politically active.

    However we should also look at things from the perspective of other types of patient. Working in London hospitals I have seen many patients who for various reasons are not registered or who have poor contact with their GP, and experience disconnected healthcare as a result.

    People who move frequently or live far from their work (e.g. students, travellers, homeless people, working people on short-term jobs, MPs) may find it inconvenient to access a local GP. They may need GP services for minor illnesses and chronic disease monitoring, but not for home visits or social services.

    I think there is a need for non-geographic GP services tailored towards the second group, and in some areas such as university campuses they already exist. However, there is a risk that they may be too profitable because they are mainly used by younger able-bodied patients, so capitation payments must be reduced to balance this.

  4. Lana Tremain says:

    I would disagree with you on that.

    I and my two children do not have a GP because we were let down badly by our previous one. I also work as an interpreter in the ones that are in my area and therefore can not be registered with them.

    There are a few other practices around that have a very bad reputation.
    Why should I have to register with them???

    There is however one practice within 1.2 miles (I drive) that is suitable and has a great review but I can not register there as we are out of their boundaries…

    In my case I believe the opportunity to register with GP of your choice is great and I hope this will be possible soon, we currently have no doctor.

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