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Saturday 1 October 2016
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Insight: Breaking Boundaries

The extension of practice boundaries from this Autumn, following the pilot last year, will have implications for practice patient lists

Many people have interpreted the roll-out of the concept tested in the ‘Choice of practice’ pilots from October this year as bringing an end to practice boundaries. This is not the case. Under changes introduced at the same time as the pilots, practices had to identify an outer boundary for their practice area (unless the area was already extensive). This boundary determines the extent of the area in which practices are obliged to visit their patients. The latest changes haven’t altered that - they simply extend to all practices the opportunity to accept on to their practice list patients who live outside the outer practice boundary (with no obligation to visit them at home) or keep on their list existing patients who have moved outside the boundary (again with no obligation to visit). Practices have complete discretion as to whether to accept or keep such patients on their list, but are advised to adopt a consistent policy in doing so. 

The impetus for these changes came from politicians complaining that: 

 - Constituents who commute to work (mainly in London) had to take time off work to visit their GP (the rationale was to allow such individuals to register with a practice near to where they worked rather than where they lived or attend as a ‘day patient’).

 - Constituents who moved home a short distance from their practices were obliged to leave their practice’s list when they wished to remain on it.

 - Key to the changes is the concession that practices accepting out-of-area (OOA) patients are not obliged to visit them if a home visit is needed. The Area Team local to where the patient lives is expected to ensure the patient can access a home visit when needed. Every Area Team has had to have a scheme in place for this. Some established the equivalent of a Local Enhanced Service (LES) offering a one-off consultation fee to any local practice agreeing to visit; others negotiated with out-of-hours (OOH) providers to establish a daytime home visiting service. Given the small numbers in the pilots, the problems of administering this have not been fully explored.  

Registering OOA patients

Accepting OOA patients raises a number of problems, including what happens if they require community or hospital services. Commissioners are concerned about who will be responsible for the costs of community and hospital care. Will the clinical commissioning group (CCG) covering the patient’s home address automatically lose a share of the commissioning budget when they register as an OOA patient, or will this only happen when the patient uses hospital or community services in the area where they are registered? 

Practices are to have discretion over whether to register OOA patients, but in exercising this need to take account of the patient’s healthcare needs. They can only do this by taking a full medical history, recognising there may be some delay in receiving their full medical records. For a patient with a long-term condition who is stable and simply requires periodic check-ups or blood tests this may be straightforward, but a patient with a complex condition or one requiring occasional hospitalisation it may be a different matter. When it comes to deciding whether to keep on the practice list a patient who has moved out of the practice area, it is even more problematic. The pilot guidance says that “When patients rely on frequent home visits it is in their interest to choose a practice within reasonable travelling distance.” So a patient who requires frequent visits who moves outside the practice area is likely to be advised to leave the practice list, whereas one who doesn’t is allowed to remain. Will this be viewed as discriminatory? And what happens if the otherwise healthy patient becomes very sick? The practice may judge it to be in the patient’s best interests to register with another practice, whereas for continuity of care the patient may wish to remain. This is likely to lead to ill-feeling and complaints. 

Outer and inner boundaries

Having an outer and inner boundary offers a flexible alternative to the closed list, as practices can refuse to accept patients wishing to register who live outside the inner boundary (provided they are consistent in how they regard such patients) and so keep a lid on numbers of patients joining the list, while still keeping on the list those who have moved a short distance and wish to remain. Many rural practices covering large geographical areas were spared the necessity to expand their practice area and could designate the existing boundary as their outer boundary. The extension of ‘choice of practice’ should make no difference to them. 

For the (mainly London) practices that find themselves with registered patients living all over the country key considerations will be: 

 - Being clear about the patient’s medical needs before registration, clarifying in advance the circumstances in which it would be sensible for the patient to consider joining a practice nearer to where they live.

 - Obtaining details of who to contact in the patient’s home area when community services, diagnostics, out-of-hours, or acute hospital treatment may be required, and of the organisation or individuals responsible for home visiting, establishing at an early stage how easy it will be to communicate with them on the patient’s behalf. 

The British Medical Association (BMA) has condemned the extension of the choice of practice pilots as unnecessary and a waste of resources. The authors of the evaluation report, which the government only published last month, admit that it will benefit only a small minority of patients. The pilots, which took place in Manchester, Salford, Westminster, and Nottingham, could hardly have been judged a success. Only 1,100 patients registered across the 43 participating practices, of which one third failed to register a single patient. 

The fact that the government has decided to roll out the scheme nationally shows that they are prepared to ignore the evidence when intent on achieving a stated policy objective. It appears to be a victory of political expediency over common sense, and seemingly flies in the face of population needs-based health planning.