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Gerada: Removal of practice boundaries will break link between GPs and their communities

Removing practice boundaries will break the link between GPs and their local population and undermine patient care, says former RCGP chair Professor Clare Gerada in a strongly worded attack on the Government’s plans to boost patient choice.break

In an exclusive interview with Pulse, Professor Gerada warned that the controversial initiative to allow patients to register with practices outside their locality would impair the ability of GPs and CCGs to plan care.

Professor Gerada also participated in a outspoken Q&A session with Pulse readers today and spoke to Pulse about her plans for primary care in London.

The former RCGP chair - who moved on from the college last month to become chair of NHS England’s Primary Care Clinical Board in London - expanded on the ideas raised in a ‘call to action’ consultation she helped to launch last week on primary care in the capital.

She suggested that the profession considered the possibility of co-locating primary care services in hospitals and giving patients a four-hour guarantee of an appointment, if resources were put in place.

In the interview, Professor Gerada also:

  • criticised the BMA and other medical leaders for failing to speak out against the Health and Social Care Act
  • said professional bodies – including the RCGP -  should take a uniform neutral stance on ethical issues such as assisted dying;
  • reaffirmed her belief that the independent contractor status of GPs should be reconsidered.

But she reserved her harshest words for the plans in the recently released GP contract deal for 2014/15 for the pilots of removing practice boundaries for out-of-area patients to be rolled out across England.

The controversial pilots have suffered from delays and a lack of patients and practices signing up. All GP practices in two out of six PCT areas chosen for the study refused to participate and earlier this year, a Pulse investigation revealed that just 514 patients had registered with an out-of-area practice and 129 people had made use of being treated as a ‘day patient’.

Professor Gerada told Pulse: ‘Removing boundaries is wrong for a [number of reasons]. It removes the relationship between the patient and their local community, and the GP and their local community, which has been there for time immemorial. It makes planning difficult – how on earth will a GP know how many patients will be on their list in the next year, or the year after? And it is not good for patients.’

Patients will not be given more choice through this initiative, Dr Gerada warned. She said: ‘Patients seem to think they will be choosing their GP, but in fact it will be their GP choosing them. If you have a choice from 60 million people, why would you choose the very sick? The ones with mental illness, those that are homeless, those with complex comorbidities.’

‘I will attract [healthy patients] by offering free membership for a gym, or at the bottom of the swimming pool because they will be fit.’

Practices are already offering patients ‘solutions for their access’, she added.

‘For years, my furthest patient lived in Portsmouth, because they could not access the sort of care they needed. But that was a drug user who I needed to provide continuity for. I think federations are the answer – federations give choice that are beyond just that practice to a much wider geographical area.’

Dr Gerada said that NHS England’s call to action in London would allow the profession to consider a number of options for transforming primary care, including co-locating GPs to help them address the needs of hard-to-reach patients.

She said: ‘If we start designing services around the patient, we will stop getting in to this territorial argument and we will start to make things better… what I am against is the idea we should move GPs lock stock and barrel into hospitals for some pragmatic reason – eg, space.’

An ‘aspiration’ to see patients within four hours would be’ good news – good news for patients, good news for general practice’, but will only be done with more resources, she added.

She criticised other medical leaders for being ‘fearful’ over opposing the Health and Social Care Act: ‘I think the Act was quite an eye-opener about how those in leadership positions were fearful of being leaders and putting their views forward in case they said the wrong thing, or upset somebody.’

She added: ‘I think the BMA were slow. When they started to be lobbied and forced to act, they did well. But they were slow to act. They didn’t inform the public and the profession what lay behind the HSCA, which is now being played out as predicted as too much, too soon and the wrong changes.’

Dr Richard Vautrey, deputy chair of the GPC, said the GPC ‘shared her concerns’ about practice boundaries. He said: ‘We made our concerns very clear in the reponse to the consultation when the Government first announced the initiative.

‘If you look at the evaluation of the limited pilot that has taken place, many of the concerns are also expressed by the PCT managers. There are lots of potential consequences of what superficially might seem like an attractive scheme.’

In terms of the contract agreement, Dr Vautrey added: ‘The agreement was that we acknowledged the Government’s intention to roll out… there wasn’t negotiation about it, it was part of the Government’s intent. It was a recognition that this was going to happen.’

However, he said that Dr Gerada’s suggestion that the BMA was slow to oppose the Health and Social Care Act was ‘complete nonsense.’ He said: ‘If we look back in history, we will find that the BMA was the first organisation to come out against the bill, even before the RCGP.’

Readers' comments (9)

  • Can the government's intention to privatise the health service be more blatant than scrapping practice boundaries ?. Private firms are going to hoover up well , cheap to run patients leaving chronic complex care to the NHS .We need to block this change now or there will be no effective NHS general practice left .

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  • Vinci Ho

    CG has become a very 'interesting' political character during this extraordinary history of general practice in this country.
    Then again , so often you have certain politician who would go independent and 'detach' from any party.
    Oh, politics , such a funny old game.............

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  • Not sure what you mean by that comment Vince!

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  • GPs and practices have to be part of CCGs.
    Independent MPs have no long term role in politics and last less than one term..

    If I am correct Claire, you said that the CCGs should be the vehicle to help formation of Federations.

    What Vince may be saying is that there is no room for any alternative model or true independence for the profession by being part of CCGs. Not funny but true.

    Have a good Christmas and Happy New Year Vince, Clair and other GPs.

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  • "If you have a choice from 60 million people, why would you choose the very sick? The ones with mental illness, those that are homeless, those with complex comorbidities.’

    ‘I will attract [healthy patients] by offering free membership for a gym, or at the bottom of the swimming pool because they will be fit."

    Interesting to see CG confirms the media stereotype of GPs as lazy, moneygrabbing types.

    If this is a known tendency, can the government not just legislate that anyone (regardless of health status) must be registered until the point that the list is full?

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  • The policy to abolish GP practice boundaries is grotesquely stupid. The proponents of this policy simply ignore the importance of geography in providing good quality general practice. Our experience over the years has been that patients living at a distance from the practice receive poorer care; at times it is unsafe. It is inefficient, and is a drag on resources.

    Another important factor is that of capacity: most practices, especially popular ones, simply do not have capacity to register patients from outside their areas.

    A limited number of healthy patients might benefit from a boundary-free system, but it will usher in numerous unintended consequences. This is an extreme example of the inverse care law.

    The politicians & policy makers behind this have simply not thought it through. I would go further: they have wilfully ignored the risks.

    My conviction is that this policy is in reality a scam. The true aim of the policy is to deregulate English general practice. The real winners will be for-profit organisations like Virgin Care. I think it is very likely that there has been behind the scenes lobbying for this for several years.

    For my submission to Parliament's Health Select Committee on this issue see

    I think the GPC needs to be more forthright about this: they should make it plain that they think the policy is wrong-headed. If the Government wants to impose the policy, it is entirely their responsibility when things do not work and problems arise. Otherwise it looks as though the GPC agreed to the policy in their contract negotiations.

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  • Many hard working tax payers cannot see a GP when it suits them as they work away from home. Hopefully on a practical level this system will help these people access care more easily. Dentist's have been able to do this for years to no apparent detriment to their patients. It is a different world to when the NHS was started and we need to change or surgeries need to meet the demands of their "communities".

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  • It is fictional to think all GP's know all their patient's in a community. Maybe some small rural practices.
    People want access and care when they need it.

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  • Regarding boundaries and continuity of care etc. I moved 8 miles away but into a new county and was told I needed to change my GP--THIS NEW SYSTEM WILL HOPEFULLY ALLOW PATIENT'S TO REMAIN WITH THEIR GP WITHOUT THE NEED TO CHANGE.

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