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Independents' Day

Should practice boundaries be scrapped?

Are practice boundaries a barrier to choice or essential for controlling patient demand? Dr Mark Hunt and Dr Mark McCartney argue their cases

Are practice boundaries a barrier to choice or essential for controlling patient demand? Dr Mark Hunt and Dr Mark McCartney argue their cases

Practice boundaries have been a barrier to choice and have unnecessarily forced some patients to move practice. It's right they should go, says Dr Mark Hunt

Across almost every aspect of our lives, the days when we gratefully took what we were given have gone. We can now choose, for example, who provides our electricity, gas or phones at home. The result is lower prices and better standards.

Over the past few years, people have begun to enjoy the same power over health services. With the help of their GPs, patients can now choose which hospital they have their operations in so they don't have to wait a day longer than necessary. But choice over which GP practice to register with remains severely restricted. Most patients can choose, at best, from a couple of local practices. But often even

this choice does not exist, with practices shutting their doors to new patients. Abolishing practice boundaries will give choice to patients who are unhappy with their current practice or find it does not meet the needs of their lifestyle.

This doesn't mean everyone will want to exercise that choice. For elderly patients with chronic disease, for whom continuity of care and proximity to their home are the most important factors, choice may not make a difference. But the take-up of choice may well surprise us, even in the elderly. Patients with specific chronic diseases such as diabetes might move to a practice with a GPSI in diabetes or one which offers a one-stop diabetic clinic.

Continuity of care is one of the most important features of good primary care, but the current system is rigid and doesn't allow patients to achieve continuity where they require it. Just ask any patient who has had to register with a new GP because they moved one street out of the catchment area of their current practice.

For those who are concerned about what happens with home visits, there is already a system in place. Currently when someone goes on holiday and they need a home visit they contact the nearest surgery and are treated under an emergency treatment or temporary resident basis.

Lack of choice is part of the remnants of a healthcare system designed for doctors, not for patients. Frankly, it's time it was changed. Patients will now be able to sign up with a GP practice near where they work rather than where they live.

For many people who work a long way from home, this is far more convenient. Taking time off work for a routine GP appointment is simply not realistic. Not everyone has a work schedule allowing such flexibility or a sympathetic boss and this inconvenience may cause some people to put off seeing their GP.

But the abolition of catchment areas will have a more profound impact on health services than simply improving convenience for commuters – after all, the majority of visits to GPs are from older, retired people. It will help drive up standards across the board.

By giving patients choice, all practices will feel a pressure to respond to patients. Otherwise they will simply go elsewhere – to a practice that opens from 8am to 8pm seven days a week, or one that offers the extra services they require. But choice only works well if patients have clear, accurate performance figures so they can make informed decisions, and the Government needs to ensure they are available.

The introduction of choice does mean some practices will struggle. We may see practices closing if they can't keep their patients. But the NHS is run to provide care for patients, not employment for doctors. Choice will allow good practices to expand and lead to improved standards.

GPs are overwhelmingly independent-minded, innovative individuals who want to improve patient care, so I am confident increased choice will see practices developing and offering new and improved services. Choice is good for patients and all GPs should embrace it.

Dr Mark Hunt is managing director of Care UK Primary Care, the largest independent provider of healthcare to the NHS, and a GP in Frome, Somerset

Practice boundaries are a vital tool to allow GPs to control demand, keep track of vulnerable patients and provide good local care, says Dr Mark McCartney

Health secretary Andy Burnham recently announced the Department of Health's sixth attempt to end practice boundaries – just as we thought the Government was going to give GPs a rest from idiotic policy.

Judging by the number of previous attempts to stop GPs limiting their practice areas, the issue must be high on the agenda of each new health secretary. Perhaps the task is given to each new minister as a test of resilience. On previous occasions, when the idea was given some consideration and planning, it was found to be extremely difficult as well as costly to implement. This time, though, there is support from the Tories, so whichever way the election goes, it seems likely that a great deal of effort will be wasted on an attempt to introduce yet more marketisation into general practice, on top of walk-in centres and Darzi centres.

Andy Burnham talks about expanding patient choice, yet we all know that his Government's policies tend to do the opposite of what they say on the tin. More choice seems to mean less – think Choose and Book. In fact ‘choice' has become a byword for giving away public services to the private sector which, as we have seen with independent sector treatment centres, cherry-picks the easy cases.

In my rural practice, we use our boundary to help control and manage our workload. We don't have room in our premises for more patients or doctors. The geographical area we cover is roughly based around the capacities of our teams, such as community nurses and social services. We have reached a balance that allows us to provide quality care for all our patients.

Disrupting this balance will lead to problems, and that in turn is likely to mean more managers and bureaucrats will be needed. I can already imagine receiving a call from my PCT ‘out-of-area customer communication facilitation manager', not to mention the ‘daytime unscheduled care home visiting financial planning officer'.

There may be some entrepreneurial GPs who see opportunities to expand their practices – picking up the healthy mobile patients, while the chronically sick are cared for by their local practice, which will see resources reduced without any significant change in workload. Some practices could become destabilised, while others could be faced with an influx of demand before they are able to expand their teams or premises.

We don't know what might happen with particularly difficult cases. How, for instance, could we keep track of at-risk children and their families, if they were allowed to register outside the jurisdiction of the local social services department? What will happen with patient allocations – those patients who find it difficult to maintain a good relationship with a GP? Will we find ourselves being allocated patients who live many miles away?

Where do patients find themselves in all this? Commuters might find it easier to get an appointment near to work – if these practices were not too busy seeing other commuters – but they might find it considerably more difficult to get care at home, if they needed a home visit and they were registered with a practice many miles away.

This change in policy is yet another cynical attempt to disrupt general practice by misguidedly creating a bigger healthcare market, and it will prove costly in financial and administrative terms. However, if it is introduced, perhaps Mr Burnham would like to extend the policy to MPs and their constituencies. Then the electorate could have a better choice of who to vote for. A health minister with 30,000 GPs in his constituency would work for all of us – patients and doctors.

Dr Mark McCartney is a GP in Pensilva, Cornwall

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