Editorials

GPs, patients, and the distance between them

The issue of coherent catchment areas for primary care is raised again by Murray and colleagues in this week's journal (p 100).¹ The problem can be viewed from two perspectives: the distance that the patient is from the doctor and the distance that the doctor is from the patient.

For most people the convenience of the nearest surgery is the main determinant of where they register.² Nevertheless, many go further afield, and historic factors may be important in their choice. When they move, those in urban areas often remain with the devil they know--"the desire to maintain a link with a doctor known to the family . . . appears to be stronger than any wish to minimise the distance travelled to the practice premises."³ The availability of a woman doctor, and, for patients from ethnic minorities, doctors from their own cultural group, may also be important.

Since 1948, when a salaried component was added to the simple equation between capitation and income, there has been little evidence that doctors retain migrants or accept allcomers for financial reasons. The majority of patients on most urban general practitioners' lists live within the practice's catchment area. This limits unnecessary travelling, facilitates care with local teams, and ensures that local populations do not lose out to more distant but mobile patients. But maintaining the right of patients to choose within limits seems a desirable option and one that services should be capable of accommodating.

The more acute problem is the distance that doctors are from their patients. Although most people report that distance is not an obstacle to access, for those most in need, including elderly and disabled people and those dependent on public transport, distance is often an important constraint. The negative effect of distance on the use of general practice services, both at the surgery and at home, has been repeatedly documented over the past 20 years.^{4 5} Knox has described how the changes in the locations of general practices in Aberdeen between 1950 and 1973 reinforced the geographical patterns of disadvantage.⁶ (Their amalgamation into group practices and their failure to devolve from city centre to peripheral housing estates made access more rather than less difficult.) Most general practitioners breathe a sigh of relief when new premises are built. Siting, however, is often a parochial affair, dependent on personal preference, the availability of a site, and the location of the list rather than on any wider considerations of geographical equity.

Under the present system some measure of social planning is at least conceivable. Patch and locality planning is beginning to emerge, adapting services to the needs of local populations and their providers.⁷ Whether this option to rationalise primary care services will remain is questionable. Perhaps we should be thankful for two things: firstly, that each patient does not have 87 different doctors as may happen in market driven systems that have abandoned gatekeepers, generalists, and continuity, instead favouring primary access to a multiplicity of specialists.⁸ And we should also be thankful that general practice is not yet beset by the problems of the education service, with basic provision limited by distance in the state sector and choice limited by ability to pay in the private sector. Equity, of either access or quality, does not appear on the agenda of a government currently bent on establishing such a two tier service for primary care.⁹

Even forward thinking administrative authorities are floundering. There are neither adequate structures nor policies capable of dealing with coherent planning for primary care. In many places the destabilisation of hospital services has compounded the problem, and fewer managers and planners at district and regional levels are likely to add to the chaos.

Additional payments for deprivation have improved some unacceptably low medical incomes. But more substantial measures will be needed to prevent the widening divergence in access to and quality of primary care services, which is increasingly apparent both locally and regionally.¹⁰ Efficient distribution of resources is inextricably related to equity. Current policy does not address this, and, as Murray et al point out, the problems have not gone away.

General practitioner Chrisp Street Health Centre, London E14 6PG1

J Robson 

1. Murray SA, Graham LJC, Dlugolecka MJ. How many general practitioners for 1433 patients? BMJ 1995;310:100.
2. Ritchie J, Jacoby A, Bone M. Access to primary health care. London. HMSO, 1981.
3. Phillips DR. Spatial patterns of surgery attendance: some implications for the provision of primary health care. J R Coll Gen Pract 1980;30:688-95. [Medline]
4. Morrell DC, Gage HG, Robinson AN. Patterns of demand in general practice. J R Coll Gen Pract 1970;19:331-42. [Medline]
5. Parkin D. Distance as an influence on demand in general practice. Epidemiology and Public Health 1979;33:96-9.
6. Knox PL. The accessibility of primary care to urban patients: a geographical analysis. J R Coll Gen Pract 1979;29:160-8. [Medline]
7. Jarman B, Cumberlege J. Developing primary care. BMJ 1987;294:1005-8.
8. Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart GL. The content of ambulatory medical care in the United States. An interspecialty comparison. N Engl J Med 1983;309:892-7. [Abstract]
9. Hart JT. NHS reforms. BMJ 1994;309:739. [Free Full Text]
10. Dixon J, Dinwoodie M, Hodson D, Dodd S, Poltorak T, Garret C, et al. Distribution of NHS funds between fundholding and non fundholding practices. BMJ 1994;309:30-4. [Abstract/Free Full Text]