The removal of practice boundaries has been a chief concern of practice managers. Yet with the recent hiatus in the Health Bill's progress through parliament to allow for the government's 'listening exercise', and furore over GP-led commissioning, you'd be forgiven for thinking that this wasn't going ahead.
But in April 2012 practice boundaries will cease to exist in England. This is not open to debate. The Department of Health's (DH) consultation closed in July 2010 and the government is already overdue in releasing detail on how this will work – but a reversal is not on the cards.(1)
There can be no defence for being caught by surprise, as it was mentioned by both the then shadow health secretary Andrew Lansley and the former Labour Health Secretary Andy Burnham back in 2009.
The political thrust behind this move lies with a desire to drive up quality by getting patients to vote with their feet if they feel their GP surgery is not up to scratch. This is in line with patient-centred care, allowing patients to decide whether to register with a practice near their work rather than their home, for example. It's a crowd pleaser but the logistics remain problematic.
Since the abolition of boundaries was suggested, practice managers have vehemently expressed concerns to Management in Practice that remain unchanged today, around funding, home visits and ballooning – or shrinking – list sizes.
The British Medical Association (BMA) said the plans would "mean a major change in the way GPs and other healthcare staff provide their services", while the NHS Alliance raised questions over "funding, continuity of care, risk of mismanagement and clinical error". In an Alliance survey of GP practices and primary care trusts (PCTs) last year, 68% of respondents opposed the mere extension of practice boundaries.(2)
At present, the bulk of GP practice pay comes from the global sum in the General Medical Service (GMS) contract. A key concern over free registration is how funding will be organised so that any practices suffering from the 'commuter shift' – whereby healthy patients change practice while older and chronically ill patients are less likely to move – are not penalised.
Barbara Martin, Practice Manager at Northlands Wood Practice in the Haywards Heath 'commuter belt', says: "There is a concern that those patients who only go to the doctor maybe once or twice a year will register with a doctor near where they work, while the high-demand, high-dependency patients with complex conditions are the ones who will want to come to us."
Furthermore, she maintains that, since patients generally want to see their doctor when they are not in a fit state to travel to work, rural practices and surgeries on the outskirts of towns will be hardest hit. As she says: "If the patient is registered with a London practice but they're seeing us, is it fair that the London practice gets the funding?"
In contrast, Mostafa Farook, Practice Manager of The Barkantine Practice, close to Canary Wharf in East London with its huge commuter base, welcomes the potential flood of new patients. The 15,000-list practice already operates a walk-in service for local workers, but this is currently a "one-off service" that doesn't support continuity of care.
Mr Farook says: "The abolition of practice boundaries could be a good opportunity to register those patients with the practice and provide regular care." By registering, he says, commuter patients would then get the practice's "whole range of services to cover their healthcare issues". His practice has estimated that they will attract between 7,000-8,000 new patients once free registration is a reality.
Despite welcoming the potential of additional funding, however, he says the devil is in the detail. "We don't know the government's actual plan. There are a lot of issues involved – home visits and how those services will be covered when we accept patients from outside our boundary – those sorts of issues need to be resolved and the government needs to come up with a full package of ideas."
Indeed, while the government's health white paper of 2010 did indicate that 'funding will follow the patient', the question of how this will compensate non-urban practices affected by the 'commuter shift' has yet to be clarified.
Furthermore, practices are currently penalised financially if they feel they are too heavily subscribed and cannot accept more patients. Under their contractual arrangements, a GP practice can only turn down an application to register if the PCT has already agreed that they can close their list to new patients, or if they have other reasonable non-discriminatory grounds. Practices with a closed list can be prevented from offering profitable new enhanced services to their existing patients while they work with the PCT to reopen their list.
If a popular practice were to attract many new patients and close its list, would the practice still be liable for a financial penalty? It's difficult to determine the potential impact of this – there are 6,324 GP practices in England, but the DH has no central information about the numbers of practices who are currently not accepting new patients.
Detail has yet to emerge that could satisfy practice managers on this issue. A DH spokesman told MiP that the issue of practices closing their lists to patients has been highlighted in the consultation and will be discussed with GPs "in due course".
And it's still not clear how the administrative side of this will be dealt with. Practices will be paid according to the number of patients on their list – but there are concerns over how the patient's pathway through the system will be 'tracked'.
"They say the money is going to follow the patient, but that will be back and forth like a yo-yo," says Anna Richardson, Practice Manager of The Surgery in Stanford-Le-Hope, Essex, which is on the border of a practice boundary.
The DH believes the positive outcomes of free registration could offset any additional administrative costs. A spokesman told MiP: "The funding implications of giving patients choice of GP practice are being looked at, but there is compelling evidence that getting quick, convenient access to general practice ensures people get diagnosed and treated more effectively, preventing more costly treatment later in hospital.
"To keep it in context, we expect the majority of people want to stay with their current GP practice or choose a different one near to where they live. This should have minimal funding implications. For the smaller number of people who may register away from home, we believe the costs and benefits can be balanced."
Estimates from patient surveys suggest that around 5% of patients would register with a non-local practice if they were given the opportunity. A larger percentage of people (up to 20%) indicated that they would like to register with a different local practice.
Home visits and IT
One of practice managers' main concerns surrounds home visits. What if a patient required urgent attention at home, yet had registered with a practice in another part of the country?
Most of the 5,500 respondents to the government's practice boundary consultation (a third of which were healthcare professionals) felt that PCTs – to be replaced by GP commissioning consortia – should ensure appropriate arrangements are put in place to allow people who are registered away from home to continue to receive the appropriate urgent care.(1)
The DH suggested in October 2010 that consortia would be asked to provide an "in-hours home visiting service" where necessary, and that a contractual agreement between commissioner and GP practice be made.1 This is yet to be confirmed at the present time, but practice managers say this would still require significant extra work for them, as well as raising issues of patient confidentiality.
"We will have to be calling another surgery to get an idea of the patient's medical history if they wish to be seen here," says Carol Wotherspoon, a practice manager and partner at Riverside Surgery in Buckinghamshire. "The Summary Care Record (SCR) is far from a reality so the keeper of the notes will have to be the port of call. Perhaps patients should be told they can only register in a different area from where they live if they agree to their notes being uploaded [onto the SCR]?"
For many practice managers in England, progress with the SCR is the central issue that should make ministers reconsider their April 2012 deadline. If this were to be delivered so that medical records could safely and quickly be accessed by any of the cross-border healthcare professionals treating the individual patient – with the patient's express consent – then, many accept, the abolition of boundaries becomes a viable deal.
But that's a big 'if'. Caroline Kerby, Joint Lead for the NHS Alliance Practice Managers' Network, said: "I don't believe that the IT infrastructure is in place. With the billions that have been spent on IT, we still don't have a joined-up primary and secondary care system."
In response to these concerns, the DH said: "Our engagement with clinicians and commissioners has highlighted the issue of access to clinical records if people are able to register some distance away from home and may, on occasion, need to access local urgent care services.
"However, access to records alone does not preclude opening up choice for patients, as many already use a range of alternative services in other settings, including A&E, walk-in centres and out-of-hours providers without access to records.
"A number of GP systems already have, or can accommodate, the facility to share records, and as the SCR rolls out, access to patient records will continue to improve."
Perhaps practice managers being too negative. While much of the detail evidently needs to be worked out, isn't there a compelling case for the principle behind the abolition of practice boundaries?
Even Dr Laurence Buckman, Chair of the BMA's GPs' Committee (GPC), which has raised serious objections to the government's plans, accepts that "complete free choice of registration is a good idea in principle and we want patients to be able to choose the GP surgery that is right for them".
In February, Dr James Kingsland, President of the National Association of Primary Care, gave a rare note of support for the proposals at a Public Bill Committee, telling MPs: "The competitive aspect of it is sometimes what makes practices great. It improves the quality of practice, because we learn from colleagues' successes and look at other practices in the area and aspire to achieve what they have, and it moves the agenda forward."(3)
Furthermore, boundaries by their very nature don't exactly enhance choice for vulnerable patients who may wish to continue seeing their longstanding GP if they move home.
Devon Miles, a patient from Suffolk, told MiP: "I agree with the proposals and to do it sooner. I need to stay with my GP of 15 years to gain the correct treatment and not put extra pressure on another surgery to treat me. For me, this means the freedom to move near family for support and to rest assured I get the treatment I deserve, with no inconvenience to anyone in the process."
Practice managers still need convincing, it seems. In an online MiP survey, 70% of readers polled believed the removal of catchment areas would not benefit patients, while 25% said it would. Arguments raised so far over the impact on patient care cut both ways.
Indeed, the idea that patient choice is universally improved by free registration is itself debatable. As the BMA said in its report on practice boundaries last year, "patients will only be able to choose to register with a practice outside their local area if they have access to private transport or affordable regular public transport. Similarly, those too frail to travel very far will be unable to exercise their choice effectively."(4)
Despite benefits for individual patients such as Devon Miles, above, the removal of practice boundaries would seem to indicate a rethink of how practices both work out and act upon local disease prevalence data.
As Dr Clare Gerada, Chair of the Royal College of GPs, told MPs, boundary removal "opens up the question of who is responsible for the total population. Provision may well be made for emergency care if you fall down in the street, but there will be nobody responsible for the total population as far as I can see. We have concerns about that."(3)
A similar point was raised by Dr Douglas Russell, Medical Director of NHS Tower Hamlets, in March this year. At the launch of the King's Fund's Quality of Care in General Practice inquiry report, he described plans to abolish practice boundaries as "bonkers".
"You can't think about the population you're responsible for if you don't know who the hell they are," Dr Russell said. "One of the practices we work with is in Canary Wharf, where 60,000 people arrive and commute in. If they all wanted to register with the excellent practice on this doorstep it would have to expand by a factor of 10 to be able to cope."
If, as Dr Russell suggests, a practice is attended by patients coming from a range of different areas, that practice's capacity to understand its patients' needs and its local public health priorities – for instance, prevalence of diabetes, obesity, smoking and drinking – is inevitably compromised.
Practice managers will need to work differently to understand the shifting demographic, according to Caroline Kerby. "We're going to have to look at social marketing models so you know the postcodes where patients come from and can get the information, so you know what they drink, what they smoke, what they do, basically what colour they paint they bedrooms. We're going to have to have really sophisticated informatics systems."
The DH, though, does not foresee such radical change for general practice's role here, but does suggest that the cross-border allocation of patient data will be an extra responsibility for GP consortia.
The spokesman told MiP: "As now, practices are responsible for assessing the health needs of all patients registered with them, and this will not change. Going forward, the GP consortium will be the responsible commissioner for any patients registered with its constituent practices, even if they live elsewhere.
"As well has having sufficient geographic focus to agree and monitor contracts for locally based services, consortia will also need to recognise that a wider choice of GP practice will mean that some of their patients may live beyond their boundaries."
The DH is due to publish a more detailed framework document, which will give guidance to PCTs on the steps they can take during 2011/12 to prepare for patients' choice of GP surgery from April 2012. Guidance for practices themselves, however, is another matter.
It's curious that with less than a year to go, practices are still in denial over this issue. As Anna Richardson said: "I don't know anyone who is holding meetings about this. People are not expecting it to happen, or hoping that it won't happen."
This is a view reflected even in urban practices that could see their patient lists soar. Janet Pascoe, Assistant Practice Manager at Chrisp Street Health Centre in Poplar, near Canary Wharf, told MiP: "To be quite honest we don't know how really this is going to impact on us yet. Among the doctors, the practice manager and myself we haven't had a heavy discussion about it. We're just awaiting guidance when and if it happens."
But practices should be under no illusion that it will happen. If anything, Mr Lansley's springtime delay over NHS reform amid anxieties over the role of the private sector makes this public-pleasing policy more, not less, likely to move forward.
Despite the negative views, there may be reason to be cheerful. Free registration may present an administrative challenge, but it also presents good practices a chance to increase their patient list size, and therefore their income.
Even those opposed to the change can recognise that good practices will continue to succeed. As Anna Richardson says, "People won't go to GPs they don't like or don't feel they're getting a good enough service from. It will separate the wheat from the chaff."
1. Department of Health. Response to Consultation: Your choice of GP practice: a consultation on enabling people to register with the GP practice of their choice. London: DH; 2010.
2. NHS Alliance. Extending GP Boundaries. London: NHS Alliance; 2010.
3. Public Bill Committee, 8 February 2011. Available from: http://www.publications.parliament.uk/pa/cm201011/cmpublic/health/110208...
4. British Medical Association. Reforming general practice boundaries: GPC review. London: BMA; 2010.