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Boundaries plan gives patients choice – but impossible decision

Abolition of practice boundaries will force patients to choose between daytime convenience and urgent home visits. What happens if they get the punt wrong?

Patient choice is about to come of age. That, at least, is the view of its advocates, following the Department of Health's release of its initial proposals for the abolition of practice boundaries. It is not only that all patients, wherever they live in the country, will be offered an array of options for the practice at which they can register. Most have some choice of nearby practices already, and although the menu is set to be widened substantially, the nature of that particular decision is not fundamentally altered.

No, the much bigger choice for patients will be what tier of general practice they decide to register with. Do they want the full-on local service, where a GP they know and trust will provide home visits for them on the rare occasion they need them? Or will they opt for tier two – choosing convenience of access to their workplace but accepting that the quality of daytime urgent care, should they need it, may no longer be top-drawer?

As health secretary Andy Burnham puts it, patients will be faced with a ‘trade-off'. Rather than simply picking between a number of essentially similar options, they will also get to weigh the risks and benefits of two fundamentally different NHS offerings, and decide which is suitable for them.

The DH would argue this is simply treating patients like grown-ups. As its consultation document puts it: ‘Some patients will have had no need for or experience of home visits. For them, the benefits of choosing a practice they can conveniently access for routine care may far outweigh the fact the practice is unable to carry out a home visit on the rare occasion (if any) it is needed.'

Patients who are generally healthy are being asked to take a punt on the fact that they will probably stay healthy. But the real question is, what happens when the punt goes wrong? Can the system function when the bet fails to pay off?

The DH document suggests PCTs might provide home visits directly for patients who opted for the second-tier service, or else contract them out to out-of-hours providers. It is remarkable that just as our out-of-hours services are engulfed in chaos, and the PCT commissioning model has become widely discredited, ministers are looking to extend the very same system to daytime care too.

In practice, though, it might not come to that. There will be times when GPs feel emotionally blackmailed into providing home visits to unregistered patients, particularly where relatives of the patient are at the practice. There will be times, too, when GPs will inevitably be left to negotiate their way through unfamiliar community services at a distant PCT, just to make sure a patient whose punt failed to pay off gets the care they need.

Practice boundaries, rather than being barriers to access, were intended to protect the ability of GPs to provide continuous care. The risk is that by breaking down these walls, the Government will further fragment the health service.

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