Practice boundaries

“Please may I stay with the practice, sir,” implored Fran Tier. “I've been here all my life and never really bother you.” Fran had indeed been registered with us for his two-score years and had been a trouble-free and healthy patient. Looking at his records, he had only consulted us or been brought by his mother on five occasions. The trouble now, was that Fran had moved house. He lost his job as a farm hand at Margins Farm, which lies at the practice periphery. He had secured new accommodation at Beyonder Farm, but this is three miles outwith our designated boundary. In a rural practice such as this, twenty-four furlongs (five-and-a-quarter thousand yards!) may be a relatively short distance but is outwith our range nonetheless.

Practice boundaries are necessary but set, arguably, by fairly arbitrary means. They were often drawn decades or even centuries ago and took into account natural features such as rivers and hills but roads, railways and county divisions were also considered. We have an oak-framed parchment map displayed in the waiting room, clearly demarcating our defined territory. It is far from being a perfect circle, with the practice centrally, but is rather an irregular, amorphous expanse of some three-hundred square miles. This area approximates to that of an average city, as I occasionally remark to my urban-dwelling, diesel-breathing colleagues.

Ours is the only practice in the town and we encompass several villages and hamlets. We do not have any other (satellite) premises. Our area overlaps a little with one or two neighbouring surgeries. Some patients over the years have expressed disenchantment with us and taken their complaints elsewhere. Conversely, we have inherited others who left (or were asked to leave!) neighbouring practices.

When they move, people can be remiss at informing us of their new details. This may be deliberate or otherwise. It may only come to our attention that a flit has occurred when we receive a hospital letter supplying a different address or when we are asked to phone a patient and her home number has an unfamiliar area code. We are not looking for reasons to get rid of patients or to keep our numbers down, but new patients are always moving into the area and we simply cannot accommodate and accumulate every patient who has ever registered with the practice.

The one group more difficult to be dogmatic about is students. We appreciate that under-graduates go to colleges and universities for only three or four years. We encourage them to register with local or campus based practices but appreciate they may be back home several times each year. There may be ongoing medical or psychiatric problems which benefit from knowledge and familiarity. If a patient is in the middle of complex treatment I tend to agree to him remaining on the list until such time as he can transfer to a more appropriate and local GP surgery. Clearly this could only occur if he was moving a short distance and not to the other end of the country or the earth.

It is also difficult to tell long-registered patients, if they are not moving particularly far, to sling their hook but a line has to be (and has been) drawn. We cannot allow this line to be expanded like an ever increasing circle in a pond.

It would be wrong to imply that practice boundaries cannot be shifted. Factors such as new housing developments or the closure or expansion of establishments have to be taken into account. As a practice, we have to change with the demography and needs of our population, but we cannot allow individuals to determine the area we cover.

Fran felt we were letting him down. He argued that he could easily hop on a tractor to get to any future appointments. He reminded me that he had never required a housecall, but that wasn't really the issue. People take unexpectedly unwell, such is the nature of an emergency, or become elderly and frail. Exceptions have been made in the past and tragedy or near disaster has been the result.

He was asking if we could roll back the borders and push back the frontiers. Instead it seemed we were pushing back Fran Tier. He did not see it, but it really was for his own good.

Dr Ken B Moody