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Scrapping of boundaries to create ‘two-tier’ GP care

By Gareth Iacobucci

Ministers have outlined radical plans to scrap practice boundaries by creating a ‘two-tier' system of general practice – with patients choosing between full home visiting services and easy access from their workplace.

The Department of Health's preferred option in its practice boundaries consultation would create dual-track registration, with only those living close by qualifying for GP visits.

But the plans, which could be in place across England as early as October, have been attacked by GP leaders for further fragmenting primary care and asking patients to take a bet on their future healthcare needs.

Under the proposals, GPs would retain visiting duties for those who lived locally, but would not take on responsibility for visits to patients registering from further away. PCTs would instead take on responsibility for providing home visits to these patients, with the option of commissioning a ‘daytime out-of-hours' service to cover them.

Trusts would also be encouraged to reward practices that attracted new patients with increased use of the ‘expanding practice allowance'.

Health secretary Andy Burnham told Pulse patients who wanted the convenience of registering near their work rather than home would have to agree to a ‘trade-off' on their GP care. ‘If someone chooses to go out of area, they may have to accept they can't get the same level of home visits,' he said.

Patients will be expected to weigh up the likelihood they will need a home visit when registering at a practice. The document says: ‘Some will have had no need for or experience of home visits. For them, the benefits of a practice they can conveniently access may far outweigh the fact it is unable to carry out a home visit if needed.'

The consultation proposes guidelines be developed to define the area within which practices will retain responsibility for visits, based on travel time.

It says the cost of PCT home visit cover would be reflected in GP contract negotiations. Practices would either have sums top-sliced from capitation payments for patients not registered for visits, or be charged for visits as they happened.

The DH consultation, released last week, admitted its preferred option could place additional demand on A&E and ambulances if patients ‘do not understand the arrangements'.

But it insisted the plan was the best way to expand patient choice while ‘preserving the strengths of general practice'.

Alternative options include GP practices arranging home visits for all patients wherever they lived, dual registration or handing all home visits to PCTs.

The GPC – which would prefer changes in temporary resident rules and possibly widening of boundaries in urban areas – said it was concerned the plans would fragment care.

Dr Nigel Watson, chair of the GPC's commissioning and service development subcommittee, said giving PCTs control of home visits would be costly and warned a daytime out-of-hours system would be ‘a disaster'.

Dr Peter Swinyard, chair of the Family Doctor Association and a GP in Swindon, Wiltshire, said: ‘There's a risk you'd have a two-tier service. For people to opt into a service that's not as good as the current one would be very strange. The bottom line is, continuity of care is essential.'

GPs also warned the plans would destabilise practices – seeing some in city centres overwhelmed with others in commuter belts losing patients.

Dr Rosemary Macrae, a GP in St Helens, Merseyside, said: ‘The concern is we'll lose a lot of the fit commuters and our practice will become unviable.'

The Government's preferred option

- Allow people to register with any practice in England with an open list, but with two tiers:

- Patients registering locally – for whom the practice would retain the duty to provide or arrange home visits where necessary

- Patients registering further away from home – for whom the PCT covering the patient's home would be responsible for providing home visits

Dr Rosemary Macrae fears her practice will lose many of its healthy commuters and become non-viable

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