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Practice boundaries hold the NHS together

In the quiet Christmas period, hoping we were all too distracted to notice, the Department of Health announced its plans to offer ‘choice' of GP practice.  All three main political parties signed up to this at the last election: from April, volunteer practices in three pilot areas in the country (including Tower Hamlets, where I work) will be asked to register their commuter population either as temporary ‘day' patients or fully registered permanent patients ceasing registration with their home practice. 

This has for a long time been the policy of the CBI, and it is easy to see the advantages for the big banks and employers in Canary Wharf and the City of London.  But for the NHS this comes with a heavy price.

Financially it makes little sense. This small pilot will cost the NHS £2m, money desperately needs to be spent elsewhere. After all, efficiency savings of 4% are being demanded from every NHS organisation, and if these efficiencies are not made (and savings of 4% have never been achieved in any health system in the world) then cuts will be made. When money is short, why spend £2m on the healthiest section of our country, when we are making cuts elsewhere for the sickest?

Where is the extra money going to be spent?  For day patients it's obvious.  As well as the patient's home GP getting a capitation fee, there will be a consultation cost for each consultation, all adding to the total NHS bill.  For patients who choose to fully register where they work, costs will soon escalate.  True, there will not be double payments for these patients, but transaction costs mount up. 

Sorting out home visits, accounting for the prescribing budget, the cost of referrals, the coordination of commissioning responsibilities, the big cost of expansion of premises in commuter areas – none of this comes cheap.  There will be dangerous lags before resources move around.  And the practices best placed to gear up to all this will be run primarily as businesses, some commercial for-profit companies, not those geared to offer personal holistic care.

But as well as the financial cost, there is the medical and social cost. If the scheme extends to children, there will be failures in child protection.  When patients need home visits, the visiting GP will be in the dark. If patients fall pregnant or have any serious illnesses that require community services and integrated team working, this will break down.

It's not enough for the guidance to state that we can discuss with our patients whether it's better for them to receive community services from our practice team, or from the team where they live.  The key point is that it's not a team if it doesn't include the GP.  A team where some members can't ever meet each other, can't read each others' records and don't know each others phone numbers, is no team at all. Serious Untoward Incidents and confidential enquiries are just waiting to happen.

This will also force a crisis in commissioning.  Well over 100,000 people migrate into Canary Wharf every day and many more commute into the City of London.  If a significant proportion of them chose to register with us, then our Tower Hamlets Clinical Commissioning Group ceases to have geographical cohesion.  This will undermine the Joint Strategic Needs Assessment with the local authority, and the Commissioning Strategic Plan. 

Instead of the NHS being able to plan around the health needs of our local resident population, with a precise geographical focus, the NHS becomes a mere collection of fragmented access points each collecting a separate fee for a separate payment by results contract.

 The NHS was founded on different principles to that.  It was based on a contract, yes. But it was a contract between the citizen (not the consumer) who had responsibilities as well as rights, and the NHS, which was designed to operate as an integrated whole. 

Just like the Health and Social Care Bill, patient choice is being used as the Trojan horse for fragmentation, privatisation, and increased costs.

Dr Kambiz Boomla is a GP in Tower Hamlets and chair of City & East London Local Medical Committee