A mixed‐methods evaluation of a pilot to remove geographic boundaries in general practice in the English NHS Stefanie Tan, Nicholas Mays, Elizabeth Eastmure, Bob Erens, Mylene Lagarde, Martin Roland 1, Michael Wright Policy Innovation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, and RAND Europe/University of Cambridge 1 Presentation to Canadian Public Health Association Conference May 2014

NHS general practice Mandatory patient registration with a practice – Practices with ‘open lists’ must accept any patient that lives in their catchment area who is ‘ordinarily resident’ in UK Practices are private, contracted to the NHS – Paid a mix of capitation (60%), P4P (25%), FFS, etc. Practice boundaries – Gradually introduced from 1980s to manage patient numbers, improve patient access, support continuity of care, facilitate appropriate referrals (e.g. to community nursing and encourage population focus – Practice boundaries negotiated with local health authorities – Seen by some as reducing convenient access to care

Current practice boundary

The Choice of GP Practice Pilot, Part of wider efforts to improve choice, access and convenience – 10 initiatives in previous decade including primary care walk in centres Pilot – Removing geographic practice boundaries of volunteer practices to improve access and convenience – In three cities, Westminster (central London), Nottingham and Manchester/Salford, April 2012-March 2013 – Pilot specifically to benefit commuters but open to all – 2 options for patients Day patient (practice paid FFS per patient visit) Out-of-area registration (capitation transferred to the new practice)

Methods Semi-structured interviews: with pilot patients (n=18), GPs and practice managers in participating practices (n=15) and managers in local health authorities (n=13) Survey of staff and GPs from pilot practices (23/45, 51% response rate) Postal survey of pilot patients (36% response rate) compared with nationally administered GP Patient Survey (35% response rate, sample of 2.75 million patients each year) Patient findings presented refer to OoA registrations only

Pilot practices 43 participating practices: – Westminster 20/53 (37.7%), Nottingham 7/63 (11.1%) and Manchester 8/102 (7.8%) and Salford 8/51 (15.7%) – 11 of 43 practices recruited no pilot patients 1108 participating patients, 71% in Westminster Pilot and local non-pilot practices were very similar In terms of national data on practice quality and patient experiences 1 Pilot patients’ reports can thus generally be attributed to their experience of the pilot as opposed to attending ‘better’ practices 1 Practice quality measured through Quality Outcomes Framework (QOF) (incentive payments for meeting annually adjusted targets) and GP Patient Survey patient experience reports

Pilot practice staff and local health authorities’ views of the pilot Practices had positive views about the pilot – 61% of pilot practices very or fairly likely to continue with the pilot – In East London (financial district and area of high deprivation), practices were very reluctant to participate without upfront funding for costs of diagnostics, referrals, etc. Local health authorities felt the pilot was not difficult to implement but identified some practical drawbacks – e.g. funding of referrals to secondary care or community services, continuity of care and transfer of clinical information between practices

Patients’ reasons for choosing out of area registration Four patient types identified: 1.Moved house but did not want to change their practice (26.2%) 2.Motivated by convenience (32.6%) 3.New to area, registered with a local practice but lived outside the practice’s catchment area (23.6%) 4.Dissatisfied with their previous practice or chose practice for specific services or GP (13.9%) 5.Not classifiable (3.8%)

Pilot patients, England Pilot patients, London’s inner boroughs Pilot patients’ distance from home to registered practice

Out of area registered patients’ experiences More satisfied than patients at same practice, area and nationally: – In general, younger, healthier, working patients are most critical of their GP experiences – Pilot patients were younger, more likely to work, had better self- reported health and more likely to commute 30+ minutes Yet, pilot patients more likely say most recent experience or visit was very good versus all GPPS patients (though not statistically significant) Perceived benefits of scheme: – continuity of care, convenience, choice Perceived drawbacks: – no adverse events reported, or issues with out of hours care, but limited pilot period

Implications for policy and limitations of evaluation The out of area registration option will be available nationally from volunteering practices from October 2014 For a sub-group of the population, the removal of practice boundaries appears to improve convenience and even continuity (i.e. for those who moved house) But at scale, there may be implementation issues: – e.g. managing practice capacity, monitoring/allocating financial resources, providing care near where participants live, etc. Limitations of study due to nature of policy pilot Pilot was very small, provides a limited indication of future roll-out of the scheme Short duration had major implications for patient numbers, patient experience of pilot, ability to collect data on adverse events, referrals, costs, etc.

This was an independent study commissioned and funded by the Policy Research Programme of the Department of Health. The views expressed are not necessarily those of the Department. The full report is available at: