Practice boundaries: the failure of the pilot
In his penultimate article, Dr Farrelly looks at the reasons why the pilot struggled to get both patients and doctors on side.
On December 30, 2011 the Department of Health issued a press release announcing a pilot of a pet policy, that of abolishing GP practice boundaries. The DH painted a rosy picture of the new boundary-free world, with one GP quoted as being ‘excited’ by the pilot, and the press nigh-on reproduced the story, as I wrote in my last article.
I knew that this pilot would run into trouble. Why? Because the policy is unworkable, at all sorts of levels. The closer these people get to making their fantasies concrete, the more silly it seems. This is inevitable.
The pilot is being run in six areas: Nottingham, Salford, Manchester, and three London PCTs (Westminster, Tower Hamlets, City and Hackney).
There are two options for patients who want to register as part of the pilot.
First, a patient from outside these areas can register as a patient with a participating practice, and this practice becomes that patient’s GP practice. The patient is no longer registered with his or her home GP. Arrangements have to be made for this patient to access care if he or she falls ill at home and is unable to see their registered GP.
Second, a patient can be seen as a ‘day patient’ for a consultation, but stay registered with their home GP. The GP is paid a fee for this consultation.
What has happened so far?
The pilot did not in fact start on April Fool’s day, the original aim. Two of the sites, Tower Hamlets and City and Hackney, decided to boycott the pilot due to concerns of the potential negative impact on local budgets and resources.
In September the DH announced a six-month extension to the pilot, with the independent evaluation starting in September 2013. It would appear that 42 practices (almost half of which are in Kensington) are at present participating in the pilot.1 I do not know how many patients have registered. (Incidentally, none of this has been reported in the mainstream press; nor, of course, by the DH Mediacentre).
It is worth noting that towards the end of May 2012 some very relevant research was published, that was not connected to the pilot. This was a study commissioned by NHS Northeast London and the City and the Corporation of London, looking at what was needed to provide commuters working in the City of London primary care services.2
The conclusion was that of the 360,000 daily workers, something like 120,000 were likely to want to register locally with a GP. To achieve this, an additional 14 practices would be needed, with 50 GPs or nurse practitioners, plus 50 nurses, and administrative staff. There is currently one GP practice within the City.
There was clearly no way that the current sole GP practice in the City (with a present patient list size of 8,650) was going to cope with the likely demand of the pilot, and yet the DH chose this as one of the pilot sites. The same problem applies to Canary Wharf in Tower Hamlets. The commissioned research and report is a practical, pragmatic, dispassionate look at the reality.
This sort of work is essential, but it is precisely this sort of analysis which has been entirely absent from this policy from the start. And this is why I think that the Department of Health, with respect to the issue of GP practice boundaries, is either stupid, or has a hidden agenda.
Will the data available to those evaluating this pilot actually help to understand the problems inherent with a boundary-free structure for primary care? There are relatively small numbers of patients and practices involved, and the model is a relatively limited one. This is not the same as wholesale dropping of geographical boundaries.
My concern is that the data will be of limited use, that the terms of reference for the ‘evaluation’ will be limited, and that the DH and Government will ignore any unwanted news, pointing to the importance of giving people choice and ‘reforming’ a system that limits that choice.
Will anyone be held responsible for the problems that arise if practice boundaries are abolished? If Andy Burnham, Andrew Lansley or others at the DH were going to held accountable should problems arise, you can be sure they would have looked into this with more care. But as it is, other people including patients will have to deal with the collateral damage.
Dr George Farrelly is a GP in East London
1 The City of London Corporation and NHS North East London and the City. The public health and primary care needs of City workers. May 2012. http://cms.pulsetoday.co.uk/Uploads/2012/12/10/y/u/f/The-public-health-needs-fo-City-workers—-May-2012.pdf
2 Farrelly, G. Patient Choice Scheme - Participating GP Practices. http://onegpprotest.files.wordpress.com/2012/12/list-of-patient-choice-scheme-practices-as-of-9-12-12.xls
For further documentation, see www.gpboundaries.org