Dilemma: Adding patients from outside practice boundaries
My partners are interested in boosting our practice income by accepting requests to register new out-of-area patients in October, when the changes to practice boundaries in England kick in. Is this a good idea?
Dr Julie Sharman: Just say no
I would advise any practice thinking of taking on patients way outside of their boundary to consider the scheme carefully – or refuse to do it altogether.
This change is a fillip to the Government’s longed-for ambition to give patients more choice over their GP, but the scheme is to be rolled out in the autumn is voluntary and it is important that you protect your patients’ health, and your own.
It is important that you consider that the safety of the telephone triage more and more of us rely on to cope with demand could be compromised by longer or impractical journeys for patients to access face-to-face care.
Exactly how home visits will work has yet to be decided, but it will inevitably lead to a lack of continuity of care if out-of-area patients have to be seen by out-of-hours providers or other GPs nearer to their home when they cannot get to the surgery.
GPs must consider their own health, because you may be taking on work that is unsustainable with longer times for home visits and rising list sizes that cannot be controlled or managed.
In refusing this scheme, you will not be on your own. Practices in Tower Hamlets and Hackney were asked to be part of this pilot a couple of years ago and they said no because they believed sensible practice boundaries are good for patients and for maintaining high quality, sustainable general practice.
In fact where the pilots were introduced here in London, the patients said ‘no’ too and the pilot was a flop with pitiful take up. Obviously patients know what is good for them too.
Dr Julie Sharman is a medical director at Londonwide LMCs
Chris Locke: Yes, but only if it is in the patients´ best interests
The majority of ‘commuter’ patients who want the convenience of registering with a practice near to their work are expected to be healthy and of working age, so practices in urban areas may judge it cost-effective to register a number of these patients.
But, elsewhere the remuneration offered may be cancelled out by the cost of time and bureaucracy involved in managing the care of patients from outside your practice boundary should they develop serious, long-term or complex health problems.
When registering out-of-area patients - or keeping on your list patients who have moved outside your outer practice boundary - you are expected to establish whether to do so is in the patient’s best interests, as in the pilot.1
For example, if the patient requires frequent home visits or regular hospital treatment, it may be more sensible for them to register with a practice near to their home. To avoid complaints of discrimination you must be seen to judge their best interests fairly and consistently. Develop a practice policy and stick to it.
A potential problem may occur if the patient’s medical condition deteriorates and they suddenly need regular home visits or hospital/community services in their home area. Arranging referral to and liaising with services a long way away may be time consuming and problematic, as will be determining where the budgetary responsibility for non-GP care resides in such cases.
Chris Locke is chief executive of Nottinghamshire LMC
Dr Andrew Mimnagh: Make sure you avoid a ‘zero-sum gain’
Urban practices may gain from this scheme, but there are dangers. There is no absolute prohibition on home visits for out-of-area patients in the current wording of the GP contract, and this could potentially be very time-consuming and costly.
If you intend on registering out-of-area patients, depending on the final wording of the scheme, you may wish to explore options such as federated working to deal with unscheduled care or setting up an acute visiting service rota for out-of-area patients. These options could mitigate any financial losses.
GPs don’t know how the scheme will work or be funded yet, and it is likely to attract patient complaints if practices enact the scheme differently in different areas. The costs of replying to these complaints should be factored in to your plans.
Make sure you have enough time and money if you want to attract new patients. The payment rates have not yet been published, so it is not possible to model how much this will cost and whether it will create income or losses.
Take care to avoid a ‘zero-sum gain’ of contracting an unsustainable volume of work, to keep your income the same while quality of service falls: this puts your contract performance at risk. Simply put: don’t add new patients if you’re concerned about how you’ll be reimbursed.
Dr Andrew Mimnagh is a GP in Liverpool and former medical secretary of Sefton LMC.
Department of Health. Choice of GP practice. 2012. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216504/dh_133411.pdf