Seeing double

Published: 15/01/2004, Volume II4, No. 5888 Page 10 11

When it arrives - and in what form - remains to be seen, but dual registration in primary care is almost a certainty, although resistance remains.

Alison Moore reports

Dual registration with more than one GP will almost certainly happen. It was included in health secretary John Reid's first policy paper, but do not hold your breath for it.

Announced at the end of last year following the widespread patient choice consultation, it may be some time until complete dual registration is introduced in full. And although the first steps down the dual path are slated to be announced later this month there appears to be a lack of enthusiasm among potential providers.

Guidance is due soon on using specialist personal medical services to provide some form of registration with more than one primary care provider, especially when PMS practices offer only a limited primary care service.

But National Association of Primary Care chair Dr Peter Smith is keen to point out that there has been no mention so far of full dual registration, which he warns would be 'thoroughly dangerous'without shared records.

He suggests that patients could register with both a healthcare professional and a primary care trust where PMS schemes provide limited services and may even be nurse led.

It is not only PMS schemes that could lead to a form of dual registration, however. The new general medical services contract will allow GPs to opt out of providing many enhanced services - such as flu immunisations or cervical cytology - but they will also be encouraged to provide extra services.

The whole issue of dual registration was mooted during discussions around the new GMS contract, but was felt to be too costly and was not pursued as part of the contract.

Difficulties were envisaged around how capitation payments would be split between practices, and which PCT would fund secondary care.

NHS Confederation GMS contract lead Mike Farrar feels many of the problems which led people to advocate dual registration can be addressed by other methods.Walk-in centres, for example, could see city-centre workers for minor injuries or single bouts of illness, while their home GP could monitor chronic illness. Depending on the circumstances, patients might also be able to register with a GP as a temporary resident.

'We can't swamp practices in the middle of cities - practices in cities have often struggled more than others to meet access targets, ' he points out. 'If there was capacity then dual registration would be quite good for some people, but we have to recognise that the capacity is not there at the moment.'

NHS Confederation policy manager Gary Fereday points out other problems with offering patients the opportunity to choose two GPs in the short term. 'Full dual registration requires the capability to transfer electronic records immediately from practice to practice, ' he says.

'This will be introduced through the national programme for NHS IT... but it will be a few years yet until capability is available nationwide.'

Any further shared care would raise issues about where GPs could refer - would a GP holding a patient's registration near their place of work be able to refer a patient to a hospital near their home, for example?

'We have to step back from saying that dual registration is the answer, ' says Mr Farrar. 'We can find some short-term answers to these issues which fall short of it.'

Having a personal GP who ensures continuity of care has been at the heart of primary care for many years, but as the new GMS contract bites, and PMS becomes permanent, it is inevitable that sometimes patients will need to see another GP because their main one can not or will not provide services.

PCTs will have to arrange for enhanced services that are dropped by GPs to be provided in other ways - perhaps by another practice which is willing to take on extra commitments, or by GPs employed by the PCT specifically to fill gaps in services.

It amounts to a challenging patchwork of care that stops just short of allowing patients to be registered with more than one GP for their normal care. In the short term, relatively few patients will be affected, but longer-term it could become normal to see different GPs for different components of care.

NHS Alliance chair Dr Michael Dixon welcomes many of the moves, but feels that however the system develops patients should have a prime registration with one GP or practice.

'You need someone to hold the ring - That is the great strength of primary care, ' he says.

'It is the one part of the NHS where you know who is responsible for your care.'

Mr Farrar agrees that the personal GP system allows patients to have a single person who acts, in effect, as their care manager, and he points out that this will be particularly important as greater emphasis is put on the care and management of chronic disease.