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Recent reports (for instance here and here) have indicated that the government is prepared to scrap the notion of catchment areas for General Practices in order to make it easier for patients to choose an appropriate doctor. The new NHS constitution allows patients increased freedom to choose, however the scrapping of catchment areas is an interesting proposition.

My work focuses on Southwark, London, so I can only really comment on the situation there, which as a densely populated urban area is likely to have a different set of issues than suburban or rural locations, however there are still a number of points to be made here.

Firstly, the idea is to promote ‘choice’ however the right to choose is captured primarily within a geographical context, i.e. proximity to a GP, or desire to use a GP that is close to work or school. However, research has shown that the majority of people (50% plus) do not actually care about their GP beyond it being ‘local’, most claim that they choose to use their closest GP. Those that do choose a GP still value accessibility, but more important factors tend to be related to the doctor’s ethnicity, or spoken language, and to the environment of the GP such as the neighbourhood it is within. Only in America, or Europe is the quality of service important; in the UK important metrics exist for assessing school and hospital quality, however an equivilent in the UK seems to be lacking. Prevalence statistics are available, but these are difficult for the layman to interpret, and they are given without context on the NHS choices website.

The main argument behind removing GP catchment areas seems to be that a) it will increase choice, and b) chocie is good. However, I offer some reasons why this might not be true.

• Catchment areas are primarily used to define the area within which a doctor is willing to make house calls. Thus it is not within a doctors interest to accept patients from too far away should this situtation arise.
• Often the catchment areas defined exogenously by a GP are much larger than the de facto catchment area defined endogenously by the pattern of patient registration (certainly the case in Southwark)
• The NHS pays doctors based on the size of their patient, and has a pretty weak structure for handling list data. A move such as this will make it much more difficult to handle registrations particularly if people want to register for convenience near where they work and then find themselves using a more local doctor on an ‘emergency’ basis when they have got something more than a cold.
• This may well create a hierarchical system of GPs based upon wealth, or some other measure of status. This may be evidenced by pronounced post-residential sorting, which will likely effect the performance of GPs in poor areas which can only attract chronically ill patients.
• How will choice be regulated, will GPs be able to close lists at will, or refuse ‘undesirables’?

My suspicion is that even if such a move went ahead it would be unlikely to create a massive upheaval, access to primary care is a very geographically limited problem as no one wants to travel great distances when ill just to go to the doctor. In many ways this approach seems to somewhat undermine the NHS rhetoric towards community health, in a situation in which everyone is choosing their GP you may find that GPs within a community do not actually reflect the needs of that community, or are not representative of the issues faced by that community because the patient register is itself a completely different community from outside of the immediate locality of the GP.

Finally, much of the agenda surrounding choice relies on the primary care commissioners within each Priamry Care Trust to ‘get it right’. I’m not confident that every PCT will be able to manage such a system, particularly if PCT boundaries become more porous and inequities between GPs develop.