Boundary reforms to shake up NHS

DoH plans to scrap practice boundaries could force an overhaul of health service funding. Tom Ireland reports.

Blurring boundaries: there is pressure from all sides to address the issue, but patients views are unclear
Blurring boundaries: there is pressure from all sides to address the issue, but patients views are unclear

To fully remove practice boundaries will take 'years and years' of legislative reform, says GPC chairman Dr Laurence Buckman.

Health secretary Andy Burnham's headline-grabbing decision in September to scrap practice boundaries appears to be unravelling into one of the most complex reforms in general practice in England since the new GMS contract in 2004.

The NHS funding system will have to change, says the GPC. Firstly, there are concerns that the Carr-Hill list-based funding formula will not be able to cope with the flow of patients between practices. PCTs will have to decide who pays when patients travel between trusts.

The GPC also argues that health inequalities may widen as healthier, mobile workers flood the best practices, while frail or rural patients remain unable to exercise choice.

There are more obvious concerns about who conducts home and out-of-hours visits when a patient lives a long way away from their GP.

GPC alternatives
The GPC has issued its own solutions in the hope of averting such drastic reform. Practices could extend their existing boundaries to the limit of practical home-visiting or use technology to conduct remote consultations, it has suggested.

Federations of practices could offer multiple locations for patients registered at any of the federated practices.

A broader national solution mooted by the GPC involves reforming the 'temporary residents' agreement so that practices that treat other GPs' patients receive a fee, much like A&E clinics or walk-in centres.

But what if the DoH will not accept these solutions? GPC chairman Dr Laurence Buckman says it is too early to think about 'asking the profession' what to do, as he did in 2008 at the peak of the extended hours dispute.

'If it was to be imposed on us, I do not know. I do not want to think about (balloting GPs) yet, I think that would be premature.

'To say this will be operational in October is nonsense. They will have to change the way the whole NHS works.'

The DoH maintains it will work through any 'technical issues' with the BMA and other groups after a consultation, due in February. A spokesman 'welcomed the GPC contribution' but whether ministers will take heed is anyone's guess.

The DoH is intent on allowing patients to register anywhere they like, something none of the GPC solutions offer. The health secretary's recent comments show the real objective is to drive choice.

'Let patients vote with their feet ...

If (practices) are not keeping up to date with services and facilities that people expect these days, they can expect to lose patients,' Mr Burnham told GP last week (GP, 29 January).

Other parties
The Conservatives seem equally committed to removing boundaries completely, claiming Labour stole their idea.

A spokesman said: 'It is up to patients which GP they want to see, not the state. We would give out-of-hours commissioning responsibility back to GPs. They will commission the service for an area, not a particular population, and send on the bill.'

The Liberal Democrats also back scrapping boundaries, but seem willing to work with the BMA to resolve 'challenges'.

The National Association of Primary Care (NAPC), meanwhile, suggests 'a central approach may not be the best way forward'. It wants PCTs to assess local needs and come up with services to match.

If a large number of patients wish to see GPs in different locations, PCTs and practices can organise an additional service 'closer to where the population migrates to during the working day', it says.

The DoH is working on a similar system to ensure patients can visit a practice that offers extended hours when their own does not.

But NAPC chairman Dr Johnny Marshall wonders if there is enough support from patients for the initiative to make any difference.

'There is already choice within a local area, yet many patients do not make use of that. I wonder whether a small shift of patients would actually make a difference.'

NHS managers have not greeted the policy warmly either. David Stout, chairman of the NHS Confederation's PCT Network, called for an explanation of 'what exactly we are trying to achieve'.

'Are we trying to deal with commuters or trying to drive up choice at a local level? There are complicated issues and we need to see more detail before we can look at the consequences,' he added.

It is hard to imagine the DoH watering down its policy and using the BMA's temporary resident system, even though Dr Buckman claims it could be operational in under a year.

But it seems harder to imagine the government reorganising the entire NHS funding system to offer patients a choice of GP when most are happy where they are.

Only one thing is for sure - there is no easy way to settle this latest dispute.

BMA concerns if boundaries are scrapped

  • Healthier, young patients likely to flood the best practices.
  • Most vulnerable and least mobile unable to exercise choice.
  • Carr-Hill formula not suited to large movements of particular patients, i.e. commuters.
  • Patients' treatment from one PCT while living in another would affect population-based PCT funding and commissioning.
  • GMS contractual requirement to visit patients at home would have to be dropped if they lived too far away.
  • Increased movement of patients across the country would require more efficient transfer of patient records.
  • 'Commuter shift' trend could have a significant impact on local prescribing budgets.
  • Cost to the NHS of bureaucracy and duplication of services.


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