Dear Vanessa Bourne, Celia Grandison-Markey, and The Patients Association,
I am a GP in Tower Hamlets. I heard the radio piece on GP practice boundaries on the Today Programme last Wednesday morning as I was driving into work. I have a particular concern about this issue.
My wife and I have been GPs in a small practice in Tower Hamlets since 1991. When we were interviewed to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ (patients living outside the practice area). It was then considered poor practice to have patients living at a distance from the practice, and good practice to serve a community of people who lived close enough to the practice to maximise access and integration with other services. We have in fact attempted to serve such a community and are pretty firm with patients who move away (as is common in inner city London practices, there is a fair turnover of patients). We have had quite a lot of experience with patients who continue to use us as their GPs even after they have moved away, and it has only confirmed us in the conviction that is not possible to deliver good quality care to people who live at a distance from the practice. The problems are directly proportional to the distance from the practice. Of course there are individual exceptions, but in general patients do not access us appropriately (they delay seeing us; they save up lots of problems which we cannot deal with in a single appointment), or they expect us to deal with problems over the phone which really require a face-to-face encounter, corners are cut, and sometimes it is actually unsafe. And on and on.
Then there is another problem, and it is one of capacity. We are currently unable to register all patients living within our practice area who choose to register with us. Demand exceeds capacity. If we exceed our capacity, then the quality of the service we offer our patients is compromised and quite quickly things become unsafe. So we have had to take the decision, in breach of the 2004 GP contract, to set a limit on our list size. As people move away, we can register more patients, trying to maintain a list size of 3,520 patients.
Now I sympathise with your wish to meet patients’ needs. There really is a problem for some to get registered with a practice that offers a ‘good enough’ service. But this policy of abolishing practice boundaries will not, as a system, solve the problem. Sure, there may be a few patients who will benefit, but the overall effect will be negative. And this for the two general reasons outlined above: 1. the complexity of providing good quality general practice and how distance impacts negatively (there are a host of other issues such as the problems with commissioning services with a budget that is for a local population, and so on); 2. the problem of capacity. In fact, this second aspect of the proposed policy makes the policy unworkable. What I mean is this: most GPs (if not all) are currently working at full capacity. If more than a handful of extra patients wish to register with a popular practice, it will impact on that practice. All practices will, at some point, reach their capacity. If they exceed that capacity, the service will suffer. If patients outside the practice area displace local residents, this will be at the local residents’ expense.
To give you an example from Tower Hamlets: CanaryWharf has a commuter population of approximately 100,000. The resident population of the Isle of Dogs is about 30,000 and is served mainly by 4 practices. If 10% of the commuters to CanaryWharf ‘choose’ to register locally, it would have a very significant impact on the local GP services.
For the reasons I have sketched above, our practice will be unable to provide services to patients outside our current practice area. We would simply refuse to do it and make it clear why. It would be perverse to look after patients who live outside our area (which we feel is at best inefficient, at worse unsafe), and have fewer places on the list for local residents.
I am afraid the politicians have made promises which they simply cannot keep. Blame them, not the GPs. Many of us are doing a very difficult job as best we can. When we are then landed with policies which make our job even more difficult and which are very poorly thought out, it is very demoralising.
Vanessa Bourne said in her contribution on the Today Programme, ‘Here we have something that has nothing to do with the patient, only to do with their address.’ I would challenge this and say that our practice area allows us to serve a local community with maximal efficiency and efficacy, and this has everything to do with the patient. The reality is that the vast majority of patient-practice transactions that take place are local ones.
So I feel that what is actually needed is attention given to raising the standards of practices in general (where this is needed), so that people do not have to travel to access good general practice. There may in some cases be an argument for some people registering with a practice near their work (but what happens when they become unwell?), but this is not the same as allowing the whole English population to register with the practice of their choice anywhere in England.
I started a protest blog about this issue several months ago, and for a time it felt mine was a lone voice. Most people were taken up with other aspects of the Health Bill (and rightly so). I was encouraged to see that the LMC conference a few days debated this issue and it would appear that the GPC is going to fight this pretty robustly in the coming months.
It is important that you are aware of the complex reasons why practice boundaries exist, and that they are not simply arbitrary lines on a map meant to deny people choice. That is not to say that there not people who experience them, understandably, as a significant frustration.
I almost forgot: I would strongly recommend you get hold of a book called The Plot Against the NHS, by Leys and Player. It is an analysis of the behind the scenes goings on in health policy planning in the past 10 years of so. It does not address this issue of practice boundaries; but it may well be that the politicians’ and DH’s reasons for proposing this policy is in order to open up primary care to large private care organisations on the Kaiser Permanente model. If that is the case, then they ought to be honest about it. And your organisation would do well to understand this so you can plan your strategy.
I wish you well in your work.
[July 2014: I never received a reply to this email]
Examples of problems (& this)when patients live at a distance from the practice:
Why did Andrew Lansley not think this through? I don’t know; neither did Andy Burnham (despite what the DH says about the so-called ‘Choose Your GP Consultation’ from a year ago). Neither of them have examined with any rigour the consequences of ‘choice’ in this case. See my email exchange with ‘Andrew Lansley’.
For the RCGP’s response to the Government ‘consultation’ on practice boundaries.
For my email exchange with the King’s Fund.
The Plot Against the NHS
Article on practice boundaries with respect to the LMC Conference