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Practice boundaries should be scrapped, says Lansley

1 June 2009

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The Conservative Shadow Health Secretary Andrew Lansley has called practice boundaries “a solid wall of defence against real choice” and says patients should have the right to choose their GP.

Speaking at the Royal Society for Arts in London last week, Mr Lansley (pictured) accused Health Secretary Alan Johnson of “doing real harm to our NHS” by failing to pursue healthcare reforms begun under Alan Milburn and Tony Blair.

He said the government’s Primary Care Strategy, published last year, did not go far enough in offering patient choice.

“The strategy made clear that GPs would still have fixed practice boundaries,” said Mr Lansley. “And they still wouldn’t be allowed to accept patients beyond these boundaries.

“Practice boundaries are a solid wall of defence against real choice. While they still stand, Alan Johnson’s promise to give us the right to choose our GP is meaningless, nothing but empty words.”

The shadow health secretary also said that GPs should be given more power and “real budgets” to strengthen practice-based commissioning (PBC).

He said: “GPs, properly rewarded, must step up to the plate and take ownership of their patient’s whole journey of care. They are the ones who can really take responsibility for helping us manage our care.”

Mr Lansley said that PBC had “stalled” due to GPs’ lack of control and “pretty pointless” notional budgets. He said that, as the “interface between us and the health service”, GPs should be able “to hold hospitals and services to account by simply refusing to send patients there if standards are not up to scratch.”

“If GPs don’t have their hands on the purse strings, then patients don’t have any real power,” he added. “Real budgets will give GPs power to respond to patient choice. But the government won’t let go.”

Mr Lansley said that under a Conservative government, reform would be pursued “consistently and effectively” through means such as patient choice, a plurality of independent  providers and devolved decision-making.


Your further comments (terms and conditions apply):

“Please Mr Lansley shut up and get out there and find out the implications of what this would mean. Patients already have fantastic choice and flexibility – you can see a doc at a city commuter station now, you can pop along to a Darzi centre if you are home late and want to be seen, these are all accessible to the commuter – but what about the patient with long-term conditions, housebound, single mum with children? They will suffer as more and more facilities would be removed from their local GP. We already have a shortage of district nurses, CPNs, midwifes and health visitors with little or no attachment to local practices, so out goes continuity of care – what is more important, the care of a pulled muscle at the local gym by a city worker or care and consideration given by a practice team to a terminal life?” – Sue Challinger, Kent

“He still needs to get someone to do his research for him. The practice boundary agreed with the responsible PCT is the area in which they (the PCT) can allocate patients to you and from which you must take a patient if they apply to join the practice list. The practice can take someone from outside the boundary providing they are prepared to visit. Perhaps, as I previously suggested, he needs to go and talk to Liam Fox (or even his own GP)” – Malcolm Wallace, Halesowen

We asked: “Do you agree with Mr Lansley?” Owing to the many responses (below) that followed, Management in Practice contacted Andrew Lansley and passed on your  comments. Mr Lansley sent the following response (13 July 2009):

”We are proposing to give patients the ability to choose practices, as we believe that boundaries limit patient choice.

“At present, GPs are not allowed to accept patients beyond practice boundaries, even where an alternative location may be more convenient for the patient, and acceptable to the practice. We don’t think it should be up to the government to prohibit patient choice in these circumstances.
“However, a practice may adopt a range of approaches to home visits, including reciprocal agreements with other practices, or via contracts with urgent care providers.”

Your comments
(terms and conditions apply):

“As an admin member of staff in a GP Surgery, it appears to me the criteria for reaching targets can be overcomplicated and not always achievable as not geared up to patient type population. Boundary is a way of controlling numbers or a practice can have too many patients than practical for size of building and number of staff it can hold. Different criteria could be applied but would have to bear in mind some surgeries would be overpopulated and then patient care could deteriorate” – Julia, Southampton

“No, I totally disagree with Mr Lansley’s statement. I think he need more homework on how primary care works. For instance, if a patient needs a home visit and he/she lives 10 miles away from his/her registered GP surgery. What happens when patients need urgent terminal care etc? So nothing personal but be practical. Maybe GPs could hold onto the purse strings but, mind you, before 1997 there was FUND HOLDING scheme. Did this work for patients? As far as my knowledge it did not work for patients” – Pipla Dewan, West London

“No. I think Mr Lansley’s point is not practical, even not necessary. Even now GP does not do the real treatment, it is done by the consultant where patient has choice in any way. It is better not to overestimate the GP’s power, which they don’t want either. No GP will take the full responsibility of treating patients” – Name and address withheld

“Two comments: why didn’t he ask Liam Fox before opening his mouth? If he wants to abolish boundaries then why not start with abolishing all consitunecy boundaries and just ask us to vote for a party and the party with most votes populates the House of Commons. This second point is just as daft as his suggestion!” – Malcolm Wallace, Halesowen

“Absolutely not. What about travel time to patients, cost to practices of travel and loss of service while doctors and nurses travel around the city? Please get real. Who takes the responsibility when a patient dies because of the travel time?” – Mike Robinson, Barnsley

“Here we go again, politicians who have no concept of how primary care works using us to gain points against one another. A vast amount of money is wasted in the NHS changing working patterns every time there is a change of government. It is about time the NHS was taken out of the political arena, and run for the good of all” – Anna Richardson, Essex

“What planet does this guy live on??” – Name and address withheld

“No, for all the very good reasons outlined below – please will someone actually pass these responses on to Mr Lansley? It would be refreshing if politicians could demonstrate that they will genuinely listen to primary care professionals before making statements that show such ignorance of the practicalities of service provision” – Julie Faller, Cambridgeshire

“No, it is totally impractical unless home visits would be carried out by the closest practice to the patient’s home and not necessarily the  practice they are registered with” – Joyce, Lanarkshire

“Yet again this is a comment from someone who doesn’t work in the profession and therefore has no idea of how unworkable , for numerous reasons, his proposal is. I am sure these MPs just talk for the sake of talking!” – Barbara Lawrence, London

“No. Wouldn’t it be nice if these politicians actually spoke to working GPs? If there are no boundaries we will have patients living miles away wanting to register – hopeless for an emergency in the middle of a surgery. Patients are given too much choice as it is and no one talks anything about THEIR responsibilities. As far as out of town patients go, we could, of course, perhaps have a ‘second surgery’ – on expenses?” – Name and address withheld

“I don’t understand this relentless harping on about patient choice. Most patients have no problem in exercising choice – if they don’t like us they will move to another practice, there are no barriers now to doing this. We are situated in an area where traffic congestion is a real problem. Doesn’t Mr Lansley realise that time spent visiting patients at home where a longish journey is involved is less time available to the vast majority of patients who come to the surgery and are happy to do so?” – Carol Wotherspoon, Bucks

“Perhaps Mr Lansley would care to join a practice on a Monday morning and then go with a GP on his visits? He would realise that the travelling time to far-outreaching areas is prohibitive. The government wanted extended hours – how can we provide these if a GP is on a visit? If a GP has to spend two hours travelling across a busy town he will not be able to see the 12 patients he could deal with in the surgery. Perhaps if he worked with the Transport Department they could work out how to improve the roads and thus solve both problems. We would be happy to accommodate him at our practice. This would also cause a problem, as popular practices providing good services would then become inundated and as a direct result patients’ care would be compromised” – S Doherty, Bedfordshire

“No. Where is the choice for patients if we are off home visiting a patient who lives 15 miles from the surgery and we are out for 1.5 hours. No choice for our other patients who want to see us! If  you scrap the boundary you have to scrap the obligation for home visits” – Liz Brimacombe, Plymouth

“I would question Mr Lansley’s views on abolishing ‘boundaries’. Surely there has to be a manageable boundary of sorts. Has Mr Lansley taken into account the need of home visits for some patients, and that if we had open boundaries, how long it may take a GP to visit some patients? I agree with patient choice but common sense must prevail. Perhaps Mr Lansley should enlighten us as to how his plans would be workable, or is there some point I am missing?” – Sue Winser, Somerset

“No – for many reasons, but the most obvious are that:
1. We have a contractual duty to visit a patient at home if the clinical situation deems this is necessary. If you have two visits at great distance apart, a good deal of time would be spent on the journey thereby less time for the GP to be in the surgery providing consultations.
2. If a GP is oversubscribed with patients wishing to join the list, the number of doctors is limited by partner choice – some doctors prefer to practice in small groups rather than in large centres, or the physical space of the surgery is limited. Who would then choose who comes on the list – a raffle perhaps? I do not believe that the shadow health secretary has deeply considered this issue” – Dr James Mehta, Hodnet Medical Centre

“They will have to scrap the requirement to visit patients at home when their condition so requires if they are to scrap practice areas!” – Name and address withheld

“No – I am no fan of the Labour Party, however practice boundaries are nothing to do with politics or restricting patient choice – they are there for practical and logistical purposes – if a patient is in need of a home visit and lives far form the surgery this would have a huge impact on the running of the practice. OOH providers would also not see these patients. There has to be boundaries to make it viable” – Bev Atkins, London

“I do not agree with Mr Lansley regarding the boundaries as he is only thinking about the choice and not about GPs, district nurses and midwives doing home visits if needed by a patient who lives some distance away from the surgery” – Yasin Husain, Birmingham

“I thought practices had to provide home visits (when needed) to their patients? So if a patient worked near this practice but actually lived 30 miles away, who would visit?! And funding from two different PCTs? Re PBC, most practices really do not have the time to play politics but would like to see improvement in services which is NOT PCT-led” – Name and address withheld

“No organisation can be all things to all people, without becoming swamped. Practice boundaries are a problem, but the root of the problem lies in the GP contract which compels visits to patients in need. Easier to keep to boundary areas than risk long commutes to outlier patients” – Russell, South West Essex

“Offering a patient choice of practice is a noble intention, but  what choice do GPs have to control their workload? Would GPs be allowed to refuse patients? Could GPs restrict their list size without the penatlies imposed by technically closing their list?  Practice boundaries, by postcode or whatever, are a practical way of managing list size. Also if there was totally free choice I think GPs should be relieved of the responsibility of home visits, else expensive GP time will be wasted in travel to distant patients” – Nic Burne, Doncaster

“‘Constituency boundaries are a solid wall of defence against real choice. While they still stand, any promise to give us the right to choose our MP is meaningless, nothing but empty words.’ What do you mean, it’s ridiculous to expect MPs to travel to meet  those voters who live miles away in their already hectic schedule? ‘While MPs have their hands on the expenses strings, then the electorate don’t have any real power,” he added. ‘The electorate need the ability to remove MPs to respond to blatant dishonesty. But the government won’t let go'” – Jack, location withheld

“If GP surgeries had no boundaries, how would we function when a home visit is needed, taking a GP away from his appointments for great lengths of time? This would not be ‘good practice’ or time effective” – Joy Pontin, Cambridgeshire