This article was first published in Pulse on 10/12/12. Here is the text, with minor variants:
On December 30, 2011 the Department of Health issued a press release announcing a pilot of a pet policy, that of abolishing GP practice boundaries. The DH painted a rosy picture of the new boundary-free world, and a GP was quoted as being ‘excited’ by the pilot. The press compliantly reproduced the DH story, presumably unaware that they were being duped, as I discussed in my previous article.
I knew that this pilot would run into trouble. Why? Because the policy is unworkable, at all sorts of levels. The closer these people get to making their fantasies concrete, the more silly it seems. This is inevitable.
The pilot is being run in 6 areas: Nottingham, Salford, Manchester, and three London PCTs (Westminster, Tower Hamlets, City and Hackney). There are 2 options: first, a patient from outside these areas can register as a patient with a participating practice and this practice becomes that patient’s GP practice. The patient is no longer registered with his or her home GP. Arrangements have to be made for this patient to access care if he or she falls ill at home and is unable to see their registered GP. Second, a patient can be seen as a ‘day patient’ for a consultation, but stay registered with their home GP. The GP is paid a fee for this consultation.
What has happened so far? The pilot did not in fact start on April Fool’s day, the original aim. Two of the sites, Tower Hamlets and City and Hackney, decided to boycott the pilot due to concerns of the potential negative impact on local budgets and resources. By mid-June, it was reported that only 12 patients had actually registered under the pilot. In August, the GPC expressed concern that there would not be enough data to give a meaningful assessment to the pilot. In September the DH announced a 6 month extension to the pilot, with the independent evaluation starting in September 2013. It would appear that 42 practices (almost half in Kensington) are at present participating in the pilot. I do not know how many patients have registered. (Incidentally, none of this has been reported in the mainstream press; nor, of course, by the DH Mediacentre).
It is worth noting that towards the end of May 2012 some very relevant research (not connected with the pilot) was published. This was a study commissioned by NHS Northeast London and the City and the Corporation of London, looking at what was needed to provide commuters working in the City of London primary care services. The conclusion was that of the 360,000 daily workers, something like 120,000 were likely to want to register locally with a GP. To achieve this, an additional 14 practices would be needed (there is currently one GP practice within the City), with 50 GPs or nurse practitioners, plus 50 nurses, and administrative staff.
There was clearly no way that the current sole GP practice in the City (with a present patient list size of 8,650) was going to cope with the likely demand of the pilot (and yet the DH chose this as one of the pilot sites). The same problem applies to Canary Wharf in Tower Hamlets. The commissioned research and report is a practical, pragmatic, dispassionate look at the reality. This sort of work is essential. It is precisely this sort of analysis which has been entirely absent from this policy from the start. And this is why I say that the Department of Health, with respect to the issue of GP practice boundaries, is either grotesquely stupid or they have a hidden agenda and are duping the public and Parliament.
Will the data available to those evaluating this pilot actually help to understand the problems inherent with a boundary-free structure for primary care? There are relatively small numbers involved, and the model is a relatively limited one (commuters largely). This is not the same as wholesale dropping of geographical boundaries. My concern is that the data will be of limited use, that the terms of reference for the ‘evaluation’ will be limited, and that the DH and Government will, as with the Leveson Report, ignore any unwanted news, pointing to the importance of giving people choice and ‘reforming’ a system that limits that choice.
Will anyone be held responsible for the problems that arise if practice boundaries are abolished? If Andy Burnham, or Andrew Lansley, or the (anonymous) elite at the DH were going to be brought back and held accountable, you can be sure they would have looked into this with some care. But as it is, they have studiously avoided looking honestly at the practicalities and risks because other people, including patients, will have to deal with the collateral damage.
Update 12/4/14: to see how this developed, see my post of 11/1/14, My concerns about the ‘independent evaluation’ of the Choose your GP practice pilot, & my post of 12/4/14, written after a colleague and I visited Professor Mays and colleagues, authors of the evaluation.