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Join me to resist boundary removal

My practice has first-hand experience of relaxation of boundaries. It doesn't work, and I won't co-operate with this policy, says Dr George Farrelly.

The health bill contains a policy to abolish GP practice boundaries, allowing patients in England to choose the GP practice of their choice ‘anywhere in England'.

It's a policy supported by more than three-quarters of the public, according to a summary of responses to the Department of Health's consultation in 2010. Proponents of this policy say that GP practice boundaries are outmoded and artificially limit choice. They argue that patients should be able to have ‘real choice', be able to register near work if they wish or stay with their trusted GP if they move out of an area. Furthermore, it is claimed opening up choice will drive up standards because it will introduce ‘real competition'.

When I first heard of this idea around two years ago, I was appalled. We are a small practice in Tower Hamlets. We are popular with our patients and often when they move they continue to use us as their GP. So we have essentially been carrying out a pilot study. It is a mess.

Distance from the practice is a barrier to care – patients attend less frequently, delay seeing us (sometimes inappropriately), and save things up and bring more items to the consultation (which cannot be dealt with effectively). They are less likely to attend booked appointments, and are less likely to attend appointments that we initiate (such as those for chronic disease monitoring), than those who live within our normal boundaries.

Care must be local

Patients who are not local cannot integrate with local essential services – the community mental health team, local health promotion initiatives, physiotherapy, social services and so on. We in primary care build up relationships with all these services and cannot duplicate this easily with a myriad of similar services in different parts of the country.

Sometimes it is unsafe. Patients may need a visit because they are too ill to travel, and if they are too distant to visit it can put an unsafe burden on the practice – which will then have an impact on the service that we are trying to offer to the local population.

The policy introduces a number of inefficiencies that are a drain on practice time – an important resource. And this at a time when we are being asked to make efficiency savings.

Above all, this mad system won't actually deliver the ‘choice' promised. Most practices are currently operating at full capacity and won't be able to absorb a significant influx of patients without compromising the quality of their service. So the promised ‘choice' is really an illusion, a scam.

Ministers say that practices can expand, but this has limits. And the popular doctor cannot expand – Dr Special can only see so many patients.

So if it is so stupid, why is the Government so intent on doing it? I think there is a sinister and hidden reason.

By abolishing practice boundaries, the game will change entirely. It will become possible for large, for-profit healthcare organisations, unconstrained by geographical areas, to open franchised health centres in various city centres and attract mobile, busy professional people who

are not particularly unwell (self-selected cherry-picking). No doubt this would be popular with some. But it would not be community-based, integrated family medicine, and it would increase the burden on those continuing to provide care for all.

Time for protest

Up to now, this policy has been below the radar. The focus, rightly, has been on other policies in the health bill. But it is going to come to a head soon with the GPC negotiating with the Government. The LMC conference recently voted – overwhelmingly – that the GPC should resist the abolition of practice boundaries ‘staunchly'.

Good-quality British general practice is a national treasure and we GPs, together with our patients, need to protect it. If this were to become law, our practice plans to adopt a stance of civil disobedience, quite openly and publicly. What if many GP practices did the same?

Remember, in the 2009 Trust in Professionals annual survey, 13% of respondents trusted politicians to tell the truth (the lowest degree of trust), and 92% trusted doctors to tell the truth (the highest). Closer scrutiny of the proposals to scrap practice boundaries will only increase this divide.

Dr George Farrelly is a GP in Tower Hamlets, east London

For further details on his protest against the plan to scrap practice boundaries, see