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At the heart of general practice since 1960

Andy Jones

Boundary idea full of holes

The latest initiative to emerge from the national listening exercise is abandoning practice boundaries. Apparently, 'many people find the nature and location of existing GP services incompatible with the way they live their lives'.

The listening exercise's advisers seem to feel that GPs are frightened to operate outside their traditional territory and compete for patients.

But is this fair? Controlling list sizes by boundaries has traditionally been the only workload protection that is ethically acceptable to general practice.

Many practices believe they can maintain the best standard of care to patients, and maintain a sense of order and efficiency, only by having stable list sizes ­ and consequently the ability to formulate business plans and care requirements.

Most practice boundaries are a consequence of historical accident. Changes happen through building developments or population movement.

Health care planning doesn't come into it. Not since we abandoned resource allocation working parties soon after 1975 has any thought gone into equating medical provision to population need. So how would GPs cope with deregulation?

One of my metropolitan colleagues favours maintaining a city centre base to avoid the difficulties of moving the practice, but then expanding up the nearest A-road into the leafy suburbs and dispensing territory. He calls this the 'lollipop approach' ­ the leafy suburbs are the delicious lollipop bit.

Another approach, which has been described to me as the 'Swiss cheese approach', would be to miss out the parts of town with high-demand patients compared with profit, and concentrate only on areas where patients are less onerous.

The Institute for Public Policy Research suggests the current policy of choice is advantageous only to the healthy, wealthy and demanding ­ Patricia Hewitt's 'worried well'. On the other hand, the institute admits that larger boundaries could exacerbate logistical difficulties, such as transport, for the elderly and socially disadvantaged.

And research has also shown that as patients move out of a practice's boundaries, they are more likely to be asked to reregister by deprivation score than by distance to the surgery. So the situation is confused.

Boundary changes are supposed to

pay for themselves ­ the process being driven by larger list sizes bringing in additional revenue. This sounds good

in principle, but the difficulties of expanding premises is bound to put many GPs off.

If surgery boundaries are deregulated, I think we are more likely to see GPs adopting 'A-road expansion' and the 'Swiss cheese approach' than more equitable health care for all.

Dr Andy Jones is a GP in Stamford, Lincolnshire

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