Dissecting the practice boundary pilots
GPs at the centre of the negotiations for the scheme discuss the implications for practices within and outside the pilot areas.
The patient choice pilot is focusing on six pilot sites in three cities – NHS Westminster, NHS Tower Hamlets and City & Hackney Teaching PCT in London; Manchester Teaching PCT and NHS Salford in Greater Manchester; and NHS Nottingham City. But it also has implications for every practice in the country, because their patients may be commuting to the pilot areas and might want to register there.
The scheme will run from 30 April for a year, during which time any patient living outside a pilot area can register with a participating practice to receive primary medical services from them. While the Department of Health has published guidance to help both pilot practices and neighbours, the outlook is far from clear for the next 12 months.1
What should GPs know about the pilots?
Dr Richard Vautrey is deputy chair of the GPC and part of the team that negotiated pilot terms
The pilot generally applies to patients who are working in the pilot areas – so, for instance, a Leeds patient could register in one of the pilot sites in Manchester, Nottingham or London if they worked there. However, the patients eligible for the pilot scheme differ from the usual category of temporary residents in that they can be people who are away from home for less than 24 hours, such as commuters. The pilot scheme does not affect existing arrangements for temporary residents or emergency treatment.
Practices should familiarise themselves with the advice available on the pilot so they know how to verify that the patient works in a pilot area and that it's appropriate for the patient to be treated by the new practice.
The DH guidance advises that if the patient needs a package of home- or community-based support, then it wouldn't be practical for a remote practice to be asked to co-ordinate treatment. The likelihood is that they will be on the whole fit and healthy, without complex health needs. When the patient wants to register, they're offered two choices – they can either become day patients or they join the pilot practice list as a temporary resident.
Practices should treat patients in the same way whether they are day cases or temporary patients – basing decisions on medical examinations and the patient's history. Therefore it's imperative that both the new and the old practice have a fast, reliable flow of information so day patients receive as good a service as if their records had moved with them. The record should be kept fully up to date by both practices so that one can warn the other if there are potential concerns, such as a patient who requests controlled drugs.
If the patient is accepted onto a practice list under the pilot scheme, the new practice receives funding. For day case patients, the practice is funded £12.93 per consultation for each of the first five consultations, with no funding after that. Fully registered patients bring the relevant global sum allocation.
The financial risk for the pilot PCTs is that new patients, whether day case or fully registered, will not bring extra funding for referrals or secondary care during the pilot – something the GPC highlighted some time ago. So one scenario that might take place if the pilot is rolled out nationally is patients who ‘play the system', by switching from one CCG to another to pursue a treatment or drug which has been rationed at their home practice.
Financially, it's unlikely to make a great difference to practices this year, especially as I expect patients will prefer to register as day cases because of the difficulty of providing home visits to a patient who commutes miles to your practice area. I think the Government wants people to use the pilot practices in the same way as a Darzi centre, and I don't see why patients wouldn't do that.
If the scheme rolls out nationally, a sudden shift in registration could leave practices in commuter towns in financial difficulty, left with responsibility for the young and old. Being a GP works because you're not seeing all your patients all the time – it's based on balance. While I don't think anyone will make money out of the pilots this year, there are still major financial implications at a national level.
What are the potential benefits and risks for practices in the pilot areas?
Dr Stewart Bingham is a GP in Canary Wharf and co-deputy chair of Tower Hamlets CCG
The day registration fee is, in my opinion, not worth bothering with – looking after day patients is fraught with potential problems when providing out-of-hours care, home visits and moving patient information between the home and pilot practices.
The main potential benefit to Tower Hamlets, where I work, is that if we develop a more fit and healthy patient population by registering local commuters, those people will use less of their health budgets than, say, a patient with a long-term condition.
There's not a great benefit to practices who hope to develop their own finances through, for instance, providing extra services such as travel clinics. We provide musculoskeletal and psychological services, sexual health screening and smoking cessation, which commuters already tap into successfully.
Of course, there could be a benefit to those practices looking to expand their practice list, but the practice where I work has been growing by around 2,500 new patients a year for four or five years now – so for us, there's no direct benefit.
The main drawback is the delay in funding when a patient registers with a pilot practice, as it could take up to 18 months to come through. If the cost per patient is, for instance, £2,000, and 10,000 new patients register within the borough, then Tower Hamlets is immediately owed £20m. Our borough is already overstretched in terms of health needs. Another drawback if the scheme was rolled out nationally might be that the commuter patients on our list lead to our deprivation payments being reduced.
The GPC has agreed to the idea of patient choice in principle, and it's true that there is a small population in the UK who can't access GP services because they work outside our opening hours. However, there still remains a lot to be resolved as the pilot goes live, given the lack of clear guidelines about receiving funding.
What are the main implications for practices outside the pilots?
Dr Paul Roblin is chief executive of Buckinghamshire, Berkshire and Oxfordshire LMCs and has led the development of one of the country's first LESs for practices outside the pilot areas
Areas like mine have large commuter populations, but you only need one patient who wants to register elsewhere for you to have an obligation to set up a system for home visits. There's not a PCT in the country left unaffected. The DH guidance for the pilot includes a template for a LES. However, while the template defines the activity that PCTs will want to purchase from GPs, the LMC must negotiate on cost.
When the pilot was announced I emailed all the PCTs I've worked with before to get an idea of suggested costs for patient attendance at the surgery they've de-registered from, and also for home visits. The offer on visits from my PCT, at £50 plus mileage, was acceptable, but the £12.93 figure for surgery attendance was not.
Given that a walk-in centre would receive £25-27 per attendance, and perhaps more for a Darzi centre (there aren't any publicly available figures for it as it's ‘commercially sensitive') we felt that PCTs needed to do more to incentivise doctors to do what will essentially be a voluntary task. GP practices are small businesses and where there's no case to take up a LES, other NHS services will pick up the slack.
The listserver, an email forum for LMCs, has been a useful resource for the process of establishing the required funding.2 But if my PCT refuses to offer extra funding I feel that others will take this as a precedent. Quite why the DH didn't create a national DES I'm not sure, as hundreds of people will need to negotiate arrangements on the same issue. It's hard to know how the loss of our patients to city practices will affect the global sum, but presuming they're young, healthy patients it could be £50-60 a year per patient. We're not sure yet what the take-up will be like. Technically, the remaining patients will be better off for funding for prescribing and referrals.
1 Department of Health. Choice of GP practice: the patient choice scheme. 2012. tinyurl.com/bowxz6v
2 The listserver is a private email resource run by the BMA for LMCs. Email firstname.lastname@example.org for access