GP boundaries
Last week GPs were mystified when the health secretary Andy Burnham announced plans to abolish practice boundaries, which will leave patients free to register with any GP of their choice, regardless of where they live. But has the government thought this through? GPs are morally and contractually obliged, when medically necessary, to visit sick patients in their own homes: the elderly; the infirm; the terminally ill. It is the government that has previously insisted on predefined areas. It might be frustrating for a patient to find he cannot register with a particular doctor because he lives a couple of miles outside the doctor's area, but if you do not stick to the boundaries, a couple of miles soon becomes 20, and before long the doctor has patients in Manchester, Birmingham and Southampton. How are they all to be visited at home then?
There is a more insidious agenda.... (cont)
43 Comments:
Wow!!! What about Polyclinics?
The Cockroach Catcher
I posted a link in my post: Medicins sans Frontier: Ethiopia & Polyclinics
The Cockroach Catcher
Just wondaering Dr.C. what happened to all those private clinics set up in London's main train stations so commuters could have instant access to a doc. on their commuting pathway ?
It seems to me that this article has suffered from the requirements of print journalism.
If it had been a blog post the tone would have be less shrill, the analysis deeper and the references more plentiful.
"worried-well" who demand the "right" to see a doctor at a time and place of their own choosing for any condition, however trivial.
There's nothing wrong with that - I have my car maintained at a time I find convenient, I have dental checkups at a time I find convenient, I shop at a time I find convenient - in fact, all the business I transact tends to be at a time that suits my schedule.
But there we are with that "business" word again. My time has value - it's perfectly reasonable for me to want to fit the doctor in at a convenient time, assuming I don't have an urgent problem. So maybe I should be prepared to recognize that and pay a little for a lunchtime slot.
It seems to me that this article has suffered from the requirements of print journalism.
If it had been a blog post the tone would have be less shrill, the analysis deeper and the references more plentiful.
+++++
Yep.
Agree.
400 words plus editing by a third party does not allow one to develop points and stylistically it was not as I would have liked it.
But we are where we are.
John
There's nothing wrong with that - I have my car maintained at a time I find convenient, I have dental checkups at a time I find convenient, I shop at a time I find convenient - in fact, all the business I transact tends to be at a time that suits my schedule.
But there we are with that "business" word again. My time has value - it's perfectly reasonable for me to want to fit the doctor in at a convenient time, assuming I don't have an urgent problem. So maybe I should be prepared to recognize that and pay a little for a lunchtime slot.
++++++++
Well, yes, but the business analogy does not quite hold up. As by inference you acknowledge in the second paragraph, you have to pay for your car, your teeth and so on. Medical services, such as they are, are free at the point of entry.
What you don't mention, though, is that you have to book your car service and dental check up in advance. Don't know about yours, but my dentist has a six week lead time for routine appointments. Sebastian and Hermione want immediate same day access to their doctor at a time of their choosing for non urgent problems.
We are moving to 24/7 supermarket medicine. if that is what people want, then that is what should be provided. But in fact it is only the young worried well fit and active people who want this. People with serious illness, usually but not always older people, are happy to wait a day or two and use their diaries so that they can see a doctor who knows them and has experience of their problems.
Don't get me wrong. Let's provide 24/7 supermarket medicine in Darzi polyclinics for those who want it. But don't force family doctors to do it. It is a complete waste of our skills. Worse, it means that we have to spend precious time dealing with Sebastian's emergency ear wax when we could better spend that time dealing with serious illness.
John
My first thought is what happens about secondary referrals? Can I live in Southampton, see a GP near my work in London because I don't like my one in S'ton but request my psychiatry referral goes to S'ton? And my haemotology to London? How will that be managed?
The whole thing must seem a nightmare for GPs. A good thing in principle but the admin of it and long term patient care for chronic conditions horrendous.
Ouch.. That's not a good situation.
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For starters, this is classist nonsense of the worst kind. Do you really mean to say that Kevin and Sharon only ever present with the most serious of illnesses? Does Tracy never consult you about her son Wayne's athletes foot or her digestive problems?
For seconders, if they can make this system work in countries that provide better healthcare than the UK (France, Belgium, Oz, NZ) then why can't they make it work here.
But we are where we are.
++++++++++++
Has someone forced you to take a position writing for the Guardian?
It is actually perfectly simple to make this work, as they do in other countries. It simply needs a fee to be paid to the consulting (or visiting) doctor for each consultation.
The problem arises because this is deeply unpalatable to the government. To leave health budgets effectively in the hands of patient behaviour rather than set in advance scares them silly.
There will be a fudge. Everyone is talking about visits, and this is a clear problem. However an even more difficult problem is likely to be those who are not at work due to illness or holiday and require an appointment in surgery. Are they to be made to go to their work location?
As a hospital junior who aspires to general practice, I'm delighted that someone is making public a lot of doctors' private concerns.
Next please: how noctors and quacktitioners are undercutting our training and experience whilst they play listening to chests and prescribing antibiotics that they know nothing about.
Anonymous (3:23) you sound a bit like a 1950's trades unionist - but I might have some respect for you if you openly admitted that your concerns are driven by self interest.
Do you have any evidence to substantiate your accusations about nurse prescribing because I have never seen any such data (although I could cite one or two studies suggesting that antibiotic use amongst the medical fraternity has been far from ideal in some cases).
Once we move beyond anecdotery Dr Crippen has NEVER been able to supply any evidence to support his thesis that quacks are dangerous/incompetent.
I expect today will be no different.
I'm sympathetic to the GP boundary issue but gratuitous potshots aimed at the quacks cannot be left unchallenged my misinformed friend.
Do you really mean to say that Kevin and Sharon only ever present with the most serious of illnesses? Does Tracy never consult you about her son Wayne's athletes foot or her digestive problems?
++++++
Of course not. But Kevin and Sharon are not as pushy as Sebastian and Hermione and do not do it as often
John
Personally? I'd happily sign a waiver regarding home visits, if I could get a GP near where I work, rather than where I live.
Given that the waiting list for appointments outside of work time at my GPs is about 25 days (the clinic allows appointments up to a month in advance) and yet I can get an appointment within 24hrs if I'm willing to go in work time - for non-urgent appointments - getting a GP near work would save me about an hour, every appointment. Maybe that sounds like a small amount, but it's an irritating waste of time, regardless.
When I retired and moved, I joined a practice that pioneered all same day appointments. I was naïve enough to think that Utopia has arrived. As long as you call before a certain hour, you will get to see a doctor, most often your own if he or she is not on holiday. I have often stated in my patch that waiting list as a concept is ridiculous. If you cannot clear your work load in one day, you will never ever do as true waiting list is never static.
In Child Psychiatry some people operate a very long waiting list so that the patients get better (which they often do) and never get to be seen. In Education they operate one so that after a few years you are already an adult and would never need the Special Education that you might need.
Well, I did think that there need to be slots for follow ups for chronic conditions including Hypertension, Diabetes, Asthma and the like but I was happy to have my routine checks on the same day as I phoned.
But same day works well for me as I can get seen between my hectic world wide travels.
Then after a few holidays, I cannot get a same day appointment.
By the time I get to see my GP, he explained (we always have a long moan about the state of the NHS anyway):
“We had the most complaints about our same day appointment.”
“PCT decided to scrap it.”
He then told me off the record that people did not like the idea of being able to see the doctor on the same day as the appointment time may indeed clash with other things they want to do as there is no guarantee it would be at the minute they want it.
“Because, there is coffee morning, ballet lessons, and other things that has priority.”
But how do they know when they are going to be ill?
“The majority fit in an appointment with their social calendar. Some want to be able to say to their employer that they have a doctors appointment and show the card.”
“No, people did not want to lie and just phone in and say they are ill!”
Well that was his experience. I suspect some middle managers can be quite nasty. From my hospital experience, more members of staff were sick during half terms and holidays.
The Cockroach Catcher
Nonsense.
The boundary system leads to patients having to travel for long periods when ill, as they cannot register at the nearest surgery to their house, or indeed at the nearest surgery of the health authority whose area they reside in, as many surgeries are not open for new registrations. Abolishing the boundary system is by far the best thing to happen to healthcare in the heavily populated urban areas where the majority of the English population actually live.
I also note that given that GPs earn rather more than average (yes, yes they earn every penny) they are rather more likely than their patients in urban areas to have a car.
It's this kind of special-interest pleading that creates the atmosphere in which the Government can paint GPs as whining and self-serving, and deserving to be subjected to the Government's diktats.
Dr C, I thought you were taking a rest?
Have we not done this debate over at Dr Grumble?
As usual you want the NHS arranged for the benefit of the providers of care and not the patients
whats greedy about working your socks off, paying lots of tax, and needing to see a GP while working miles away from home?
where is the "Equity of Provision" for diabetics who move house frequently? or travel all the time for work?
where is the "Quality of Care" for anyone who doesnt fit the neat stereotype of staying at one address continuously which the NHS assumes and provides care for?
By the way my car was serviced today, at the time I wanted, I made the appointment last thing yesterday. I saw my dentist last week the day after I asked for the appointment, I had a gum problem and he saw me no problem.
If I ring my GP in the morning, I will be unlikely to get through, will almost certainly be offered an appointment at least 3 days in the future at a time of their choosing with no choice for me
GO LIVE IN THE CENTRE OF COVENTRY AND USE THE GP YOU ARE FORCED TO USE BY THE NHS AND COME BACK HERE AND TELL ME YOU ARE HAPPY!
Burnham maybe a dick head, but current status quo is crap and must change, and I hope and pray the Conservatives blow the current bollocks away for all time after the election
Hi No One
Good to have you back.
Yes, I am resting; once a week in the Grauniad is more restful than once a day.
As you well know, we are closer in opinion than might appear; and I agree with so many of your feelings; lets tackle the problems with real solutions; this boundary stuff is a straw man.
I too would love the next government to revolutionise the NHS. Sadly, we both know that they will continue merely to tinker on the edges
John
"Sadly, we both know that they will continue merely to tinker on the edges"
I'm confident that a Conservative government won't settle for that. Pre-election they can't afford to lose public sector workers' votes by but in office, with an expected large majority in Parliament, they will have the opportunity to make the sort of reforms which "No One" and the authors of Dr Crippen's "sentient sites" advocate.
I'm looking forward to the backlash when lots of people try to register with their preferred surgeries and discover that they're full up and the lists closed. Abolishing practice boundaries won't automatically enable people to register with whoever they want.
But how do they know when they are going to be ill?
Nobody knows that, do they, Cockroach. But nobody has to.
If you're really ill, you want to see a Doctor ASAP, and you don't care when it is, because if you're that ill, you're too ill to be in work, or at ballet practice or whatever.
Lots of Doctor's visits aren't that kind of urgent care, though. Maybe I've noticed something odd happening to a freckle, and want the Doctor to take a look. Maybe I'm having trouble sleeping, have chronic pain from arthritis, or am having trouble conceiving a child.
Almost nobody wants same-day appointments at a random time for things like this - they aren't that urgent. People mostly want an appointment which is both soon and at a convenient time. My old Doctor's practice in London only offered same-day appointments, and it was enormously annoying. You had to phone first thing in the morning, and would be allocated a time slot that day. Then you'd have to take the morning off work and hang about in the waiting room for your name to be called. I'd have loved to have been able to switch to a practice that would let me phone up and make an appointment for 5pm whenever there's a slot available in the next couple of weeks, but that would have been outside the catchment area, so not allowed.
Medics posting messages on networking websites like Facebook and Twitter are breaching patient confidentiality, a leading journal reveals.
"...creates the atmosphere in which the Government can paint GPs as whining and self-serving..."
To be fair, that's hardly a challenge.
Give me a proper doctor any day, rather than GPs that misdiagnose around 60% of what comes in front of them. One that works in a hospital and actually knows what they're talking about. You know, the ones that are paid about 2/3 of what a GP gets, on average.
I'm in an unusual position due to my location. I live in a smallish rural village, with a council housing estate plonked in the middle of it, that's bordered on all sides by similar villages. We have one surgery here, the problem is that our postcode (and therefore our PCT) is not shared by any of the surrounding villages. So there are three villages, each a mile away from my village, all with different postcodes and assigned PCTS that reflect the postcode and not the area the code generally belongs to. Confused? Try living here.
The nearest village/town that shares our postcode is 6 miles away, and we are therefore ineligible to use it's GP services. This means that 3500 people are sharing 1 practice without a permanent resident GP*. For anyone with a chronic condition it's a nightmare. The recent swine flu epidemic resulted in 3 of the 4 locums and 2 or the 4 nurses being off sick, which meant all non-urgent appts were cancelled and only emergency cases could be seen. Everyone else was diverted to the local A&E dept. or told to contact the Urgent are centre (10 miles away) to be seen OOH.
The nearest village to us has 3 practices, and is a mere 1.7 miles from where I'm sitting, but I can't register there. Our next door neighbours were registered there before moving here. One of them became ill before they'd had a chance to re-register at our village surgery and the OOH doc would not visit because it was out of the boundary.
So it's all fine and dandy if you live in an urban or suburban area to say that the boundary restrictions should be enforced as they are now. When I lived in my birth town I had the choice of about 60 GPs, access to a day surgery clinic, x-ray facilities, treatment room and a full outpatients suite. Now it takes me 5 working days to get the results of a simple urine test back, in which time the doctor I originally saw has moved on, and I have to explain the whole thing all over again to the latest low-achiever to be dumped on the village.
* We do have a resident GP technically. We call her 'Manuel', as in Fawlty Towers, because she has a luxuriant moustache and can only speak pidgin English. A lovely lady I'm sure, but unfortunately a practising Catholic. I say 'unfortunately' because she's pretty much on permaternity leave. I've lived here for 5 years and when I registered she was a primagravida and due any time. She now has 6 children, so her up-time has been, shall we say, somewhat minimal.
I can't see what PCT areas have to do with boundaries. I live in one PCT area and see a GP in another PCT area. The GP's boundary isn't coterminous with the PCT boundary, it forms a rough circle round the practice.
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'Don't get me wrong. Let's provide 24/7 supermarket medicine in Darzi polyclinics for those who want it. But don't force family doctors to do it. It is a complete waste of our skills. Worse, it means that we have to spend precious time dealing with Sebastian's emergency ear wax when we could better spend that time dealing with serious illness.'
So, noctors /quacktitioners ARE a good idea after all?!
Not sure the Guardian's the place to be heard by the next government Dr.
GPs have always been the thorn in the side of soviet health care, that why they are going to try and abolish you.
Even me, I would disagree that kind of situatuon. It would be very difficult in reality.
I'd love it Dr C if my GP felt any obligation, moral or otherwise, to visit me or any member of my family when ill. It's not going to happen though is it, as you surely know!
The problem I have with this is were I live there is one GP who is very knowledgeable about epilepsy and will let my wife have a six month script (almost 1000 pills) and trusts the Consultant That GP is just outside our area. The nearest GP will only prescribe a one month script and whanted a review every 2 months
It seems to me that this issue should be considered a live one, not one for the future. While the new NHS Constitution (which includes the principle of patient choice of a GP) has not yet led directly to changes in the contractual documentation between GP Practices and PCTs to remove catchment boundaries, the obligation on GP services to actively consider patient choices is already legally enforceable. This is by virtue of the Department of Health posting the Constitution on its website, along with considerable publicity material, and in doing so creating a legitimate expectation in law. The expectation in question is that the principles outlined by the NHS Constitution should be considered in matters of decision making by relevant public bodies, or those bodies carrying out a public function.
What this effectively means for GP Practices (and, for the avoidance of doubt, this situation is due to be ratified by Parliament by the end of this month - although I believe the expectation was created as soon as the Department of Health posted the constitution on its website) is that when a GP Practice, as a provider of GP services, is presented with decisions regarding patient choice of GP practices, it is not sufficient for them simply to follow established procedures that have arisen from the existing contractual basis on which the practice supplies NHS services. Instead it is now (and probably has been since 21 January 2009) incumbent on the practice to give reasonable consideration to the representations of interested parties, and come to a reasonable solution that must endeavour to balance the interests of all parties (including, naturally, what is best for their health). This obligation applies regardless of the current contractual arrangements between practices and the PCT, due to the relative authority of the Secretary of State for Health in such matters. A failure to do this would leave GP Practices open to legal challenge.
Whether the Secretary of State for Health chooses, at a later date, to introduce more detailed rules within PCT contracts regarding GP patient lists and catchment areas (to which I expect Burnham’s comments referred) are not relevant to the legitimate expectation, already created, that NHS service providers will endeavour to keep the promises contained within the published NHS Constitution.
I am not sure this has been fully appreciated yet by GP practices, but I think this actually represents both a potential empowerment but also burden on GP practices – for on the one hand they actually have a greater flexibility around decisions on who is granted a place on their patient lists; while on the other hand they have to make sure these decisions can stand up to a test of reasonableness if challenged. So actually, under emerging circumstances, Doctor Crippen now has an entitlement to exclude the “Sebastians and Hermiones” from his practice, in favour of the elderly; the infirm; the terminally ill, as long as he can demonstrate he has given reasonable consideration to the representations of interested parties, and come to a reasonable solution that endeavours to balance the interests of all parties.
Personally I think this is a better situation all round than bureaucratic delineations of catchment areas, which, in my experience, seem primarily to act to exclude lower income patients from practices in middle class areas.
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Dr. Crippen, I always like to trade shop talk. The house calls, home visits. Is it typical for a GP to do them in your area?
My patients come from a 30-mile radius. As a practical matter, it would be difficult for me to do house calls. I guess if you count our assisted living facilities, I make a lot of house calls, because I can see a dozen or so frail elderly patients at one visit.
Hmm Dr Crippen you said but Sharon and Wayne aren't so pushy.
Seems to me that sometimes pts need to push. If I hadn't my daughter's chronic ear infections and subsequent hearing damage would never have been diagnosed. I learnt to push to late to prevent the damage though.
If my parents hadn't been told by myself to push my mother would still be waiting for a referral to the breast clinic for 'unusual' changes.
Sometimes being meek infront of a GP is not what is best for the pt.
I visited my GP about 2 years ago to discuss some long term digestive problems I'd had. I thought I found the reason for my problem and wanted his opinion. He told me quote 'you can't possibly have that condition because I've never seen a case of it'.
I ignored his sage advice, and did my own research, chnged my diet to suit, and have never looked back.
I regard GPs as overpaid charletans, who have about half a dozen fixed diagnoses, which if you fall outside of them, you're screwed.
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