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Bound to be divisive?

9 April 2010

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Supervising Editor
Management in Practice

At the time of writing, the general election looks set to be a close call, if opinion polls are to be believed. No wonder that politicians are keen to offer the public reassurances that they will make our lives easier by giving us greater access to a GP surgery – any surgery.

Strong arguments do exist for the reorganisation of general practice boundaries, but the current electoral climate has really brought this issue to the boil. For better or worse, the idea of empowering patients is seen as a vote-winner. I can’t help but get the impression that politicians want to offer greater choice to the public first, and then consider the practical ramifications later.

However, this is not the full story. Intertwined with the concept of patient choice is also a genuinely pressing need to address inequalities in the system. Significant variations in life expectancy and mortality rates exist across the UK, and primary care is acknowledged as playing a crucial role in tackling these inequalities.(1)

A landmark report into healthcare inequalities published in February claimed the wealth gap in England is responsible for people in England dying “prematurely”, losing up to 2.5 million years of life in total. The review – Fair Society, Healthy Lives – led by Sir Michael Marmot, found that the lower the socioeconomic position of a person, the worse their health.(2)

Addressing this problem is a vast undertaking and will remain one of the most pressing problems for any government. Yet the issue of general practice access and choice is so intricately tied to infrastructure that primary care policymakers will have to tread carefully if they are not to create additional inequalities. And here we come back to practice boundaries.

How the removal or extension of boundaries will work exactly is still subject to discussion. The Department of Health launched a consultation on this very subject at the beginning of March, which will end on 28 May.(3) It’s certainly a contentious issue among practice managers– the MiP website received a flurry of opposition to the proposals when the news was announced.(4)

Our readers are not alone. In January, the British Medical Association (BMA) said that, while a “good idea in principle”, plans to abolish boundaries were “fraught with difficulties” and total abolition would have a number of “unintended consequences”.(5)

For a start, not everyone will be able to access, and therefore choose from, the varied practices in their area: the frail or those unable to afford transport could struggle to register with a “better” practice further from their home, effectively creating a two-tier system.

In addition, could “at risk” patients be vulnerable if they regularly re-register with practices not within their existing social services boundary? The BMA suggests systems would need to be put in place to track and protect such patients.

Nor would a mass exodus of patients from one practice to another necessarily benefit the latter business. While funding may be reduced for the less-popular surgery, the practice that is inundated by demand could quickly find that its premises are not sufficient to cope with the influx. And then there is the issue of home visits to address …

In short, whatever the political make-up of the next government – and the Conservatives are at least as keen on extending boundaries as Labour – detailed measures and surefootedness will be required if this well-intentioned policy is not to create a ripple of unintended inequalities.

1. See
2. UCL Research Department of Epidemiology and Public Health. Fair Society, Healthy Lives – the Marmot Review. London: The Marmot Review; 2010. Available from:
3. Department of Health. Your choice of GP practice: a consultation on how to enable to register with the GP practice of their choice. London: DH; 2010. Available from:
4. See
5. See