Thursday, 18 March 2010

Practice Boundaries and Home Visits

I have an overwhelming sense of deja-vu. As part of the government's plan to scrap practice boundaries, the suggestion has been made that someone other than GP's could take over the responsibility for out of hours care - oh sorry, I mean home visits. This of course coming at the same time as GP's are being asked to take back control of out of hours care which was seized from us (albeit gratefully) just a few years ago. Unfortunately of course that grand plan has left a wake of debt, poor care and unnecessary deaths. But I'm sure it will be different this time...

The debate on practice boundaries is an interesting one. The idea of increasing patient choice is of course appealing, but is fraught with problems, none greater than how to manage home visits for patients who don't live locally. Never fear though, the Department of Health is going to resolve the problem with one of the four potential solutions:
  1. Creating rules to identify which patients practices should arrange home visits for, and which PCTs should be responsible for.
  2. Asking GP practices to continue to provide or arrange home visits for all patients.
  3. Allowing patients to register with two separate GP practices.
  4. Removing all home visiting obligations from GP practices, making PCTs responsible instead.
Here are my thoughts on the above:
  1. Logistical nightmare which would exacerbate the 'postcode lottery' effect and be wholly unfair to patients living just beyond the boundaries set (who may previously have been covered by their practice).
  2. Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
  3. Potentially workable if we had an IT system to support it, allowing both practices up to date information on consultations and prescribing. We don't.
  4. Ludicrous. Much as I grumble about home visits (home visit = no lunch break), they provide an essential service to the sickest patients. Imagine the dying cancer patient, requiring regular home visits, being seen by a different PCT doctor on each occasion? It has the out of hours fiasco written all over it. Can this government really make the same mistake twice?
It seems to me that none of the government's options are workable. Yet the push for it continues because at first glance, 'it seems like a good idea' (may win votes). Perhaps even more importantly, opinion polls show quite clearly that it is only a small minority of patients who would wish to register with a different local practice or with a practice close to work (18% and 6% respectively). Does the enormous expense that this re-structuring will incur provide the tax payer with value for money when it will benefit only a minority? With the rest of the public sector under immense pressure to cut costs, is it really as Andy Burnham would have us believe "the right move at the right time"?

The majority of patients can already choose between a number of local practices. In addition, it has always been possible to be seen as a temporary patient in any practice in the UK, giving easy access to NHS primary care services wherever you are. So my point is this, where exactly is the problem?


  1. So my point is this, where exactly is the problem?

    I'll give you an example. My disease does not respond to the treatment laid out in various official guidelines and requires a different treatment that is not part of the 'official' guidance.

    My GP is bright, autonomous and able to think outside of the box and is willing to take responsibility for the 'outside-the-guidelines' treatment.

    I know from correspondence with other patients in the same predicament, that many GPs are not so bright, are less able to think for themselves and are more interested in covering their backs and following the 'official' guidelines to the letter.

    If I happen to move to another catchment area, I will be left in the hands of the less bright, more self-interested GPs and my health will suffer as a result.

    Therefore, for somebody like me who values my current good state of health, widening practice boundaries is a good thing as it means I would be able to continue my life-restorative treatment should I have to move house for any reason.

    I imagine that on the whole, the majority of patients will stay put. However, for some people this rule change may be the difference between sickness and health. The proposed system works well in other countries and I believe it can be made to work here.

  2. Where's the real problem so long as it's fairly local? My missus and I moved from one practise area to another in the same town just over 25 years ago, and expressed a preference to stay with the old practise....this has been quietly and efficiently managed...and our kids are now at that practise too....