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Did the Government realise what it was up against on practice boundaries?

By Richard Hoey

Ministers are under pressure behind the scenes to dilute their plans to allow patients to register anywhere in England – on the grounds that they are not compatible with commissioning

Some months ago, I met up with a senior figure close to health secretary Andrew Lansley, who was baffled at the fuss the Government's plans to abolish practice boundaries were in the middle of causing.

‘We don't understand quite why GPs get so worked up about it', the source admitted, and it was said not as an arrogant dismissal, but with genuine bewilderment.

Mr Lansley will presumably have a better idea now, if only through the power of repetition, because from what I'm hearing, GP leaders have continued to place practice boundaries right up near the top of their hierarchy of concerns.

The ending of practice boundaries has been the forgotten NHS reform recently. It doesn't involve a dramatic overhaul of the NHS, or drafting in legions of private companies, so the national media, and the public, don't seem very interested in it (even though the policy is supposedly for their benefit).

But both the RCGP and the GPC are very worried by the impact that scrapping practice boundaries could have upon continuity of care, and are actively trying to find a way around the issue. Dr Richard Vautrey, deputy chair of the GPC, reiterated his concerns last week that no boundaries plus no NICE was a formula for ‘medication tourism'.

He warned consortia could even operate like a closed shop and collectively choose not to provide a treatment, to prevent patients from hopping from one consortium that did not offer the treatment to another that did.

There's also the problem of a consortium potentially having to commission some care for patients living in their area who aren't registered at a member practice or, even more nonsensically, a consortium commissioning care for a patient registered at a member practice, but who lives many miles away.

You would think therefore that the solution might be to restrict choice of practice to those within a single consortium. Certainly, one leading GP told me that option has been discussed, and that they feel there's a reasonable chance of getting it adopted. I was given the impression that some sort of compromise could be on the cards.

But there are problems with such a solution too. Another senior GP recently described to me a hypothetical, mid-size city that isn't Leicester but is somewhere quite like it, which is divided up between two consortia, who have to deal with a single hospital for many of their services.

How, this GP wondered, would restricting patients to a single consortium work in such a situation? Some practices in the neighbouring consortium might be really quite nearby to a patient.

And both consortia would be commissioning services city-wide, so it wouldn't be any more problematic for them to be registered at one consortium than the other.

Those might seem fairly academic points, but it's exactly these sorts of situations that will be highlighted by the national media if the Government does concede ground on its promise to allow patients in England to register with any practice in the country.

Ministers may now be a little clearer on GPs' objections to their proposals. But the route to any sort of compromise still looks mired in muddle and complexity.

Richard Hoey, Pulse editor

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