Government plans to scrap GP practice boundaries by October this year have taken a knock following criticism from both the British Medical Association and the NHS Alliance.

Proposals to allow the public to sign up with any GP in the country regardless of where they live instead of being confined to areas close to the home were announced by Health Secretary Andy Burnham in September last year, the idea being that such a move will make primary care services much more accessible to the public and better tailored to their own health needs.

In a different approach, the Conservatives have said that instead of dismantling boundaries they would enable patients to register with the practice that best suits them - either closer to where they live or where they work - in order to improve the public’s access to primary care.

While the BMA agrees that patients should be able to pick their GP practice of choice for care, it warns that scrapping boundaries altogether would have “a number of consequences for the organisation, provision and funding of all NHS services and some aspects of social care,” which, it stressed, all need careful consideration before a decision is reached.

For one, it says that IT schemes such as the electronic patient record transfer will need to be implemented quicker to ensure that all GPs have access to full patient records to enable them to make the right clinical decisions, and new systems for protecting and tracking ‘at-risk’ patients who are regularly re-registered at practices outside of their social services locality will also be a necessity.

In addition, it points out that breaking down the boundaries could have a potentially negative impact on health inequalities, as frail patients or those unable to travel may not be able to access practices further away, which may offer better services than those closer to home, putting them at a disadvantage to those patient who can.

Funding difficulties
Moreover, a complete overhaul of the GP and primary care trust funding systems would be needed to take into account fluctuating patient numbers and demographics, as well as the ripple effects on hospitals and social services, which will be further complicated by patients registering with family doctors outside of the PCT region, it said.

The NHS Alliance has also been critical of the plans, citing concerns over funding, continuity of care, risk of mismanagement and clinical errors as well as health inequalities.

The group carried out a survey of both clinicians and managers in PCTs and GP practices, which found that the large majority - 68% - were against the extension of practice boundaries, while 91% said catchment areas should remain in force to “identify patients for whom the practice has a duty to provide home visits where necessary”.

While it also supports of improving access to primary care, the organisation stressed that any move towards boundaries extension “should not lose sight of the importance of continuity of care and personalised care which patients currently receive in their local practices”.

“At worst, we could end up with some practices cherry picking the less ill and more remunerative patients leaving those most in need of heavy duty care being unable to get it,” said NHS Alliance chairman Michael Dixon, and warned: “In short, the drive to greater choice might lead, especially for the most vulnerable, to a narrower range of options.”

Following its review of the government’s proposals, published yesterday in the paper Reforming General Practice Boundaries, the Association has come up with its own solution which, it claims, will widen choice and improve access to GP services.

According to the BMA, the “most sensible” way forward for the NHS in the current climate is to rehash the current arrangements for treating “temporary residents”, so that people can have access to the full range of general practice services “on an immediate basis when they are away from their registered practice more effectively”.

GPs already have an obligation to provide treatment to temporary residents (classed as being in one place for more than 24 hours but less than three months) under the current General Medical Service contract, but the Associations says funding for these services “is based on a single historic allocation that is in many areas outdated”.

The current arrangement should be revised, it argues, so that GPs can treat all unregistered patients on an ad hoc basis as well as a temporarily resident one, and that introducing a ‘payment by results’ funding mechanism would ensure the appropriate reward for each care episode, much like how the A&E attendance system works.

Local solutions
In addition, the BMA suggests a series of local solutions to help boost access, choice and efficiency, such as widening practice boundaries in urban areas and introducing videophone and webcam consultations, driving care deeper into the community.

“Having worked through various alternatives, we believe this solution is the best option for the health service at this point in time,” commented Laurence Buckman, Chairman of the BMA’s GPs Committee, explaining: “Not only will it be the most cost effective solution, it will also serve patients far better. They will get more choice and are less likely to be adversely affected by the new set of problems that total abolition would create”.