Practice boundary abolition is far too risky

All the major political parties agree that they would like to abolish practice boundaries.

The GP Record, by Fran Orford www.francartoons.com
The GP Record, by Fran Orford www.francartoons.com

A large majority of the public want to be able to see a doctor of their choice, or near their work - and who can blame them? It sounds easy, logical and sensible. Patients could register with whom they want, where they want. There could even be dual registration, with a 'home' GP and a 'work' GP.

But there are three major concerns: the effect on the 'home' practice; the effect on the 'distant' practice; and continuity of care.

'Home' practices risk becoming destabilised. Practice profitability stems from having a large cohort of fit adults who consult infrequently: the real workload comes from the elderly, the housebound and the chronically ill. Many practices in rural areas and dormitory towns may become financially non-viable if their healthy commuters re-register in the cities. If these practices close, who will look after their remaining patients?

What about the effect on city practices? The Isle of Dogs' 30,000 residents are served mainly by four practices. What if a sizeable proportion of the 100,000 commuters to Canary Wharf chose to register with them? How would they continue to care for their local population?

Who will have clinical responsibility for commuters outside office hours? How far is deemed 'too far' for a home visit? Ten miles? (Sensible in the country, ridiculous in cities.) Who will care for commuters taken ill at home, if 'home' practices have folded? Will they have to attend casualty for unscheduled (and therefore expensive) care?

Without doubt, dual registration and/or abolition of practice boundaries could be made to work. But it would need a seismic shift in the way that GPs are paid; and a quantum leap in the quality of intra-GP and GP-hospital communications to guarantee continuity of care between two distant GPs and all their local hospitals. None of these changes can happen overnight: all will be expensive. To eliminate practice boundaries without first implementing all these features would be a recipe for disaster.

The abolition of practice boundaries poses a far greater risk of NHS destabilisation than ever there was from the Health Bill - yet few outside the profession have sensed the danger. The politicians are sleepwalking into disaster.


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