Don’t ditch evaluations just because pilots are hitch-free

By Nicholas Mays

PIRU’s experience with the ‘Choice of GP Practice Pilot’ suggests the need for continuing independent evaluation of policy roll-outs, 

The greatest benefits – and potential disbenefits – of any piloted policy change are usually felt in the longer term and after roll-out. Yet evaluations are often quite short term, sometimes ending before really important issues emerge and possibly even cast a shadow over the enterprise. So we should think carefully before we ditch evaluations once initial pilots show few or no major hitches.

PIRU has evaluated a pilot that let patients register with a GP practice even if they lived outside the practice’s catchment area.  Some 43 practices in three urban areas, half of them in Westminster, were involved in the 12 month pilot and just over a thousand patients registered ‘out of area’.  About a third taking advantage were commuters, often young, working and in good health. About a quarter were moving house and keen to retain their GP practice, while another quarter had picked a local practice only to find that, though they were technically outside the practice catchment area, they were able to register. Finally, about one in seven used the option to register out-of-area for different reasons, such as wanting a practice that offered specialisation in a particular condition.

In short, the pilot revealed a small number of generally positive patients. There were a few practical problems but they did not seem insurmountable. Armed with these findings, the Government recently announced the scheme’s roll-out across the country on a voluntary basis. Our evaluation finished when the pilot ended.

Yet that is really just the beginning, rather than the end of the story. Roll-out will affect not just a thousand but possibly hundreds of thousands of patients, as well as hundreds of practices  – not just in the pilot areas of Westminster, Salford, Manchester and Nottingham City. The pilot was for 12 months, but some of the practices did not register any ‘out of area’ patients until six months and a quarter of the practices didn’t register any at all. The roll-out will carry on until further notice. It is likely to gather momentum as the option of ‘out of area’ registration becomes increasingly widely known. But we don’t really know the full consequences. Why? Because the roll-out is essentially an experiment. Yet the evaluation has ceased.

What should any further evaluation look at?  It would be good to be able to look at the set up and running of this scheme on a national basis and to assess the overall impacts in terms of costs, usage and health outcomes. There are some important other questions to answer.

First, will there be problems managing GP capacity in areas with large inward and outward flows of patients? For example, a GP from a rural area expressed concern to me about the potential flight of mainly young, relatively healthy commuters, who might prefer to register close to their work (as our evaluation suggested). These comparatively infrequent, fitter users of health services partly cross-subsidise older, more frequent users. The GP feared that their loss might challenge practice viability in rural areas.

At the other end, some GPs in London have expressed concerns about striking the right balance of care between residents and incomers. Some GPs feel their practices are already over-stretched by a high-need, elderly population with multiple long-term conditions. They worry about resources being diverted by an influx of younger commuters attending with mainly self-limiting conditions. Practices might end up not having the capacity to register local residents who would then have to travel further and register out-of-area themselves.  GPs also worry about the consequences of patients staying on their lists when they move house even short distances beyond the practice catchment, particularly if they are elderly and require home visits.  In a congested city, this could make a big difference to the number of patients that the doctor can see in a day.

More broadly, we have yet to see whether loosening the rules of registration may lead to lists becoming socio-economically segregated and how that shift might be managed in terms of the allocation of finance to different practices.

Second, there are also the unexplored issues of the challenges and costs to CCGs of funding diagnostics and hospital care for those registered with GPs far from their homes. It will be important that the numbers of out-of–area patients registered with practices within CCGs are kept up to date, so undercounting does not lead to underfunding of the CCG.

The system will also need to be sensitive to the possibly rapidly changing needs of patients registered out of area. For example, a pregnant woman might wish to receive her ante-natal care close to work in London, but access peri-natal, delivery, post-natal and paediatric care closer to home. Similar issues may arise with patients requiring continuing care. Will GP practices be flexible about de-registering and re-registering patients in such circumstances?  And how well will emergency primary care be provided to patients near where they live when they are registered with practices elsewhere?

We can expect that at least some of these issues will cause problems. The fact that the ‘pilot’ phase of this scheme has not been long enough to explore them raises questions about the purpose of pilots. Researchers tend to think of a pilot as an experiment before a programme’s adoption. Others see pilots simply as feasibility studies. More often than not, the fact that a pilot has been set up shows that it already has a lot of government support and roll-out is essentially a done deal, with the pilot designed to spot any big wrinkles and to deal with critics.

Whatever the truth about pilots – and it probably varies across government – we do need to appreciate that roll-outs often remain, as in this case, experiments just as much as the initial pilots. No doubt NHS England will monitor developments. However, knowledge and policy would benefit from further in-depth, independent evaluation of how things are working out.

Nicholas Mays is Professor of Health Policy at the London School of Hygiene and Tropical Medicine and Director of PIRU. He is lead author of “Evaluation of the choice of GP practice pilot, 2012-13: Final Report”, published by PIRU in March 2014.