Department of Health response to my second email to Jeremy Hunt


This is the Department of Health’s ‘response’ to my second email to Jeremy Hunt:

Our ref: DE00000813924

Dear Dr Farrelly,

Thank you for your further correspondence of 13 October to health ministers about the removal of GP boundaries in six primary care trust (PCT) areas .  I have been asked to reply.

I am sorry that you were dissatisfied with the Department’s previous response (our ref: DE00000807059).  However, there is little I can add on the matter.

With many people working some distance from home, it is not always convenient for them to see a GP in the area in which they live.  The piloting arrangements were introduced to allow patients, who wished to do so, to register with a practice away from the area where they live, perhaps closer to where they work.  Arrangements are in place to ensure that, should patients wish to register away from home, they are still able to access primary medical services should they need them when at home.

The arrangements were trialled in a limited number of areas and the results have been evaluated and passed to NHS England.  It will be for that body to decide whether they wish to roll out the arrangements on a wider basis.  Should you wish to raise your concerns with NHS England, you can do so at the following address:

NHS England

PO Box 16738

Redditch B97 9PT

Tel: 0300 311 22 33


I am sorry I cannot be more helpful on this occasion.

Yours sincerely,

Lindsey Cox
Ministerial Correspondence and Public Enquiries
Department of Health

On recognising and naming MOOspeak from @Dhgovuk & @DeptHealthPress


The Department of Health is a large organisation, with different departments performing different tasks. No doubt, there are some departments carrying out noble and important work, and many of the civil servants working at the DH are, I am sure, dedicated to trying to make a positive difference to the provision of healthcare in the UK (or is it just England now?).

But there are some departments, the ones handling the more politicised policies, that are having to plan, promote, and implement policies that are not actually positive ones, and where there are significant unintended consequences. During the debate surround the Health and Social Care Bill many criticisms and misgivings were articulated. The Department of Health was then having to defend these policies and the methodology by which they were being planned, and this was most evident in the statements issued to journalists in response to the critiques.

‘A spokesman for the Department of Health said, ………’; ‘a spokeswoman for the Department of Health resplied…..’. These statements were understandably designed to minimise the damage done by the critique of the moment, but it meant that they were often fatuous and disingenuous. And what was frustrating from the point of view of those of us who work within the health economy was the, for the most part, the journalists just accepted these statements at face value, even if they contained falsehoods.

An example of this was when, in February 2012, 154 senior paediatricians (including 19 professors) wrote a letter to the Lancet to voice their concerns about the damage that would be done by the Bill. This naturally received attention in the press.

The Department of Health’s response, as quoted in this article:

A spokeswoman for the Department of Health said: “We have listened and substantially strengthened the Bill following the listening exercise. It’s not true to say that the Health and Social Care Bill will fragment children’s healthcare. In fact, the Bill will help address the very concerns about fragmentation that the experts raise. It will help the NHS and other public services work together better for children, young people and their families. These 150 individuals represent just over 1% of the total members of the Royal College of Paediatricians and Children’s Health and cannot be taken as an accurate representation of the College, who we continue to work with.”

The template for these responses is seems to be something like this:

a) make a positive-sounding statement (‘we have listened and substantially strengthened the Bill’); b) refute the criticism (without responding to the substance of the criticism); c) make some positive-sounding noises about the policy (the Bill ‘will help the NHS and other public services…’; and, sometimes, d) undermine the credibility of those voicing the concerns (as in this case).

What struck me about this example at the time (and why I kept the links) was that some anonymous spokeswoman at the Department of Health (who almost certainly had no experience working in paediatrics or medicine and was in all likelihood a PR person) was implicitly afforded equal status in this debate. So we had some paediatricians saying one thing, countered by the (unsubstantiated) assertions of a ‘spokeswoman’ without any qualitifications. Paediatricians 1, Department of Health 1.


What we need is a basic analysis of these communications from the Department of Health, a deconstruction. And where the DH statements are dishonest, disingenuous, misleading, and just meaningless spin, they should be named and ‘outed’ in an efficient way.

For the moment, I am going to use the term ‘MOOspeak’, but I would be happy for any suggestions for a better term. Remember, it needs to be short so able to be used on Twitter.

I would suggest that if a journalist feels the the statement they receive qualifies as MOOspeak, that they write something like:

A spokeswoman from the the Department of Health, issued this MOOspeak statement: ‘Blah blah, etc…’

Or: A MOOspokesman for the Department of Health said, ‘Blah blah….’

Or: In a statement from the Department of Health, which sounded awfully like MOOspeak, …..

I think they would issue fewer MOOspeak statements and we would have a more honest discussion.

And then, perhaps, we could move on to politicians and their ‘speak’….

My Submission to the Health Select Committee on GP practice boundaries


[I sent this Submission to the Health Select Committee in May 2013. I have not heard from them.]


Submission by Dr George A. Farrelly, General Practitioner, regarding the Government policy intending to abolish GP practice boundaries. This submission is made in a personal capacity, though I believe I represent the views of many GP colleagues.


  • The Government and Department of Health wish to abolish GP practice boundaries, saying that it will increase patient choice, drive up quality, and remove anachronistic constraints.
  • From my perspective as a GP with 25 years’ experience of trying to provide good quality general practice to a local community, this policy may sound attractive on the surface, but in reality will simply not work and will cause general practice to malfunction; in some cases it will be unsafe.
  • The Government and Department of Health are either remarkably stupid, or they have a hidden agenda and are engaged in an elaborate deception.


1. I am a GP in Tower Hamlets. My wife and I have run a small practice in Bow for 22 years (I had worked in Islington before that). The practice has grown, and we have two part-time salaried GPs and a GP registrar. Our aim has always been to provide good quality, evidence-based family medicine with a human touch. We are part of a local network of 5 practices in Bow (practices in Tower Hamlets are all part of a Network; there are 8 Networks). We are a training practice; we teach medical students.

Before studying medicine at St Bartholomew’s Hospital Medical College, I did an undergraduate degree in history (Harvard University, Magna cum laude), and a postgraduate degree in International Relations (LSE, MSc, Distinction).

In addition to my core job as a GP, I was Medical Director of the Tower Hamlets Out of Hours GP Co-Operative from 1997 to 2004. THEDOC, as it was called, provided out of hours GP cover for the Tower Hamlets population.

I feel very fortunate and privileged to be working as a GP. I feel very fortunate to be working in Tower Hamlets which has a tradition of committed GPs working collaboratively to provide good quality primary care for our population, and we have had the support of a forward-thinking PCT.

Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

2. As GPs we serve a local community. Over the years, in our practice, we have had much experience looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney, and who have wanted to remain registered with us.

We have found that living at a distance from the practice creates a barrier to care. We have found that these patients tend to delay being seen; that it is more difficult and time-consuming to manage their illnesses; sometimes they are too ill to travel to see us, and we are unable to visit them. At times it is unsafe.

As a result, we are firm with patients who move out of our practice area and ask them to register with a local GP.

And so when in 2009 politicians began to say that they wished to abolish practice boundaries, we were bewildered.

3. There are two main reasons why this proposal makes no sense:

a. first, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; this becomes increasingly significant in proportion to the severity of the patient’s health problems. (1)

b. two, because GPs are all currently working at full capacity (indeed, in some cases, beyond their capacity). The ‘good’ practices are already ‘full’ and cannot accommodate a significant increase in demand. There is a risk that ‘outliers’ will take the place of local residents, or impact negatively on the services of local residents (further discuss in paragraph 5 below).

So there is a very serious design fault at the heart of this policy. For over two years I have been attempting to draw attention to the problems inherent in this policy by blogging, writing to MPs, and to journalists. Last Autumn I wrote 6 articles for the GP publication Pulse on this issue (2). And I published these articles on a separate self-contained blog. (3)

4. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But the replies I received from the Department of Health simply did not make sense. (4) And so over time I have gradually come to the view that the evidence (evidence that is in the public domain) points towards a more disturbing process at work: that there is a hidden agenda behind this policy. My hypothesis is that the real aim here is to de-regulate general practice. At present, because it is geographically defined, it limits the type of business model that can be used to gain access to general practice. By removing the geographical element in primary care, you change significantly the business models and frameworks that can be applied.

But in order to abolish GP practice geographical boundaries, it has been necessary to create a pretext, or a series of pretexts. A narrative has been created and it has these elements: most people are happy with their GP; but some are not, and they should be able to have choice; GP practice boundaries constrain choice, they are old fashioned, anachronistic; there are a number of reasons why patients might want choice: to have a GP close to work, to register with a GP near their child’s school, to remain registered with their trusted GP should they move away; there might be a GP skilled in a disease in a practice outside their area; the only thing that is needed to make it all work is to sort out how visits will be done should the patient need one.

What this narrative leaves out are the two areas mentioned in paragraph 3 above: the systemic problems of patients living at a distance from their GP, and the problem of capacity. It also fails to mention the problems inherent in providing visits for people registered at a distance from their practice (see paragraph 9 below).

5. Some additional notes on the issue of capacity.

a. In our practice we have struggled with this. Because we are popular, people have wanted to register with us. This has driven us to a list size beyond our capacity which has a negative impact on the quality of the service we provide for our patients, and we have a workload which is unsustainable. The only way we have had to cope with this was to shrink our practice area further a few months ago. So there is no way we could cope with an additional influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised in 2010); we are drowning as it is.

b. I came across an example recently which illustrates this problem quite eloquently. There is a practice in Kentish Town with a long established reputation; just the sort of practice that people for several miles around might want to join (if I did not know better, I would consider joining as they are less than 2 miles from where I live). If you go to their practice website you will see the issues they are wrestling with as raised by their patient representation group: they are having trouble providing access to their own patients to the GP of their choice. And those are their currently registered patients, all of whom reside within their practice boundary. (5)

c. Another example illustrates this in a farcical way. The Department of Health chose City and Hackney PCT as one of their pilot sites. The City of London is served by one practice, which has a list size of under 10,000. As it happens, the City of London Corporation and NHS Northeast London had commissioned a study into the practicalities of providing primary care services to the commuter population of the City and this was published. The conclusion was that something like 120,000 of the 360,000 commuters were likely to want to register with a GP practice in the City, which would require 50 more GPs, and additional practice nurses and infrastructure (6). So there was really no way that the sole City practice was going to be able to cater to commuters interested in taking part in the pilot.

6. Andy Burnham, then Secretary of State for Health, went to The King’s Fund in September 2009; in his speech he announced his Government’s intention to abolish GP boundaries within a year. He said this move would make a ‘good’ NHS ‘great’ (at least this is what the press reported; I have asked the DH to show me the press release for this occasion; thus far they have been unable to produce it). But what he said about this in his speech really amounted to nothing, it was meaningless to anyone who understands how general practice works (and does not work). (7)

7. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice was launched in March 2010. If you look at this ‘consultation’ with a critical eye it is clear that it steered the readers towards responding in certain ways to the questionnaire. It used the narrative outlined in paragraph 4 above.

When it published the results of the consultation, the DH claimed it showed that the public backed the idea of choosing your GP practice and doing away with practice boundaries. Of course it showed that, it was designed to show that. Had they been honest about the reality of general practice, the respondents would have said: given what you have told us, why are you even proposing this policy? (8)

8. The Department of Health agreed with the GPC to hold a pilot around this policy. (9) The pilot is in progress. The present Government went so far as to say, in their Mid-Term Review, that this pilot was evidence that the Government had improved the NHS. “We have improved the NHS by …..—allowing patients in six trial primary care trusts to register with a GP practice of their choice.” (10) What the report omitted to say was that GPs in two of the six PCT areas opted to boycott the pilot because of concerns of the impact on resources of the local health economy (one of the many problems inherent in this policy).(11) What they also failed to say was that out of a possible 345 practices in the pilot areas, only 42 practices had opted into the pilot, and that as of the beginning of the 2013, only 514 patients had registered with a practice under the scheme. (12)

This ‘pilot’ in no true sense tests this policy. The Government and DH say that there will be an independent evaluation of the pilot. Given their behaviour so far, my concern is that the ‘evaluation’ will somehow avoid scrutinising the policy itself, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

9. The problem of visiting. People on all sides of the debate have acknowledged that the issue of visits would need to be addressed. But what most people have failed to grasp is the magnitude and breadth of this issue. At present, all patients are visited by their own GPs within working hours (8am to 6pm [or is it 6:30?]), Monday to Friday. And if the call is outside these hours, then there is a local arrangement for how these visits are covered. There have been problems with out of hours provision, with some high profile cases where patients have died due to not being assessed properly.

If this policy is enacted, then every area in England will require a structure to provide care for those who live at a distance from their registered GP. This provision will have to cover not only the out of hours time slots, but will of necessity be 24 hours a day, 7 days a week (because they will not have the cover of ‘their’ GP during working hours).

It is also important to understand that when a patient is seen out of hours, the notes from the encounter are sent to the registered GP. Almost always the notes contain a message that says something like this: ‘If not improving, for review by own GP.’ The trouble with the boundary free model is that there will be no local GP to manage the patient while unwell during working hours and at home. The out of hours service does not provide continuity of care, and does not arrange further investigation and referral where this is warranted.

10. There are a number of issues I have not mentioned in this submission, and this is by no means a complete critique of the proposed policy.

11. I think there is a case for finding a way to make good quality primary care accessible to people who work long hours at some distance from their homes. But the people designing a solution would have to adopt a sound methodology which would include honesty, common sense, and truly taking into account the ecology and practicalities of general practice.

12. Normally, if politicians or Government departments make unrealistic promises the media often provides a valuable corrective by scrutinising and challenging the claims. In the case of this policy, however, mainstream media have failed in this role, I think mainly due to ignorance of how general practice works. There have been three main waves of (limited) airing of the GP boundary issue in mainstream media: at the time of Burnham’s visit to the King’s Fund in September 2009, the launch of the Consultation in March 2010, and the press launch on 30/12/11. The mainstream press articles which appeared on those occasions essentially took the claims of the Department of Health (often misleading) and merely repeated them, as though they were ‘true’ and based in reality. (13) The mainstream press may at some stage wake up and review this issue.

13. I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent.

14. I am writing as what some might call a ‘whistleblower’. That a busy GP, in a private capacity, should have to spend all this time in trying to get this message through to the politicians and those handling the levers of power seems to indicate that something is wrong. I am writing in the hope that you will listen and scrutinise this policy.

I am also writing so at least at a future date, should the policy be implemented and  the inevitable problems surface, politicians and the Department of Health will not be able to say ‘Nobody warned us.’


George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

1. For an article which illustrates aspects of the problem, see an article by an inner city GP ; for some examples from our own practice.

5. Difficulties of a high quality practice providing access for their patients. This is a very common problem; essentially, most practices are looking after too many patients. This is a capacity issue.

My second email to Jeremy Hunt on the fraudulent GP practice boundary policy


Dear Jeremy Hunt,

I sent you an email on 8/9/13 raising concerns about a Government policy. I received a ‘reply’ from a Department of Health official (for my original email and the reply, see below). A first year GCSE student would have no trouble seeing that this is no reply at all: it is a bland, seemingly innocuous, description of the ‘pilot’ into general practice without boundaries. It does not address my concerns at all (1).

I ended my first email with a quote from my submission of May 2013 to the Health Select Committee:

I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent (2).

The DH reply only reinforces my hypothesis that this policy is a scam, a deception, a confidence trick.


I have been following the development of this policy for over 3 years now. I have not been able to find an example, a metaphor, which would help people to understand the sheer stupidity of this policy. And then last week I came across a news item that I think is of help. Briefly, it is this: a British entrepreneur was convicted in April 2013 for fraud; his fraud was selling bogus bomb detectors to the Iraqi government. He made a lot of money; the bomb detectors did not work; innocent people were blown up; these bogus devices are apparently still being used in Iraq to ‘protect’ the citizens.(3)

I believe this story, this parable, offers a structure that helps make sense of the policy which you, as Secretary of State for Health, have inherited. There is a product, a technology, which is said to perform a function (detect bombs, avoid disasters); the technology is marketed (presumably there was promotional material; presumably it came in a box with reassuring messages on the box); the buyer is persuaded to pay for the technology; the technology is put to use; the technology does not work.

(This sad, shocking story raises a number of questions which I will not address here; but one question is this: why did they not test the device? Presumably the entrepreneur and his firm told the buyers that it had been tested, perhaps they said the device was already being used in other war zones).

Now let us come back to the policy of abolishing GP practice boundaries. British general practice is a complex technology which by its very nature is local, geographically based. Our experience has been that when people move away from the practice area it is no longer possible to look after them properly, especially if they are unwell. So when I heard politicians saying that boundaries were old fashioned and limited choice I was bewildered. I heard Andy Burnham say that this policy would transform the NHS from ‘good; to ‘great’, that poorer patients would be able to take advantage of services that were offered to richer patients; I heard them say that this policy would promote competition and that this would drive up quality. Most of what I heard was very foolish, it did not make any sense, it was nonsensical, it would simply not work, it would not deliver what they were promising, it would actually undermine our work.

Now just in case you think I am some sort of eccentric, some nutty GP who has an absurd bee in his bonnet, ask yourself this: why did the former GPC Chairman Laurence Buckman describe this policy as ‘bonkers’? And why did the annual LMC conference in 2011 vote unanimously (something unheard of) a motion urging the GPC to resist this policy ‘staunchly’?

So, Mr Hunt, what I am saying is this: the technology your Government are proposing simply does not work. Your predecessors, the various promoters of this policy (politicians, the Department of Health, aided by compliant journalists and think tanks) have presented the public with an attractive box, with catchy packaging, which promises a great technology. But the device in the box is bogus, it does not actually work. Just like the bogus bomb detector. They have done no honest testing of the technology in the box. You pretend to test it, as with the sham pilot and the questionable ‘evaluation’ (4).

You see, Mr Hunt, I understand the technology. This is my area of expertise. And I am saying that the technology that your Government is promoting is very faulty and it will not deliver what you are promising. Either you are all remarkably stupid or you are perpetrating a fraud.

The entrepreneur who committed the bogus bomb detector fraud has been arrested, charged, convicted, and sent to prison for his fraud (but not, apparently, for the harm he has caused to a large number of people).

If I am correct in my hypothesis that the Department of Health and ministers are engaged in a deception, a fraud, then should they be charged? And if not, why not?

So what do I propose? I propose that the Health Select Committee open the box and scrutinise the contents carefully, honestly, dispassionately. But are they capable of doing this? I am sceptical. When the Chairman of the Health Select Committee, Stephen Dorrell, was phoned by a Pulse journalist following my submission in May, he said he was broadly in favour of the policy: ‘Where there is choice different people will have different ways of solving the problem and provided that they are all consistent with the commitment to universal delivery of high quality care then I think that the [option] which allows people to consider different ways of solving shared problems is in the interests of all patients.’ (5) This is typical of the rhetoric that is used when discussing this issue; the word ‘choice’ is inevitably used, ‘high quality’, ‘interests of all patients’. But it means nothing. It is all packaging, spin. It does not address the technical problems at all. Mr Dorrell needs to open the box and look at the technology inside the box, not to approvingly describe the packaging.

There is of course another very important question here that I feel, as a professional and as a citizen, needs to be addressed. What is wrong with the system that we have come to this? How is it that policy has been allowed to develop in this way? This is not just a ‘blunder’.

So perhaps it would be better for an independent body to look at what is in the box.

I would also propose that journalists wake up. Look inside the box, ask if it really performs the functions that the promotional material claims (but, for heavens sake, do not use the DH as your source of information). Ask questions; educate yourselves, try to understand the ecology of UK general practice. If any of you are interested, I would be happy to take you through the issues in plain English. Who knows, there might be an Orwell Prize at the end of it all.

Mr Hunt, you have a real problem here. If you implement this technology the problems will become apparent, the design faults will be exposed. You will no longer be able to fall back on the attractive box and the glossy promotional material. You will not be able to say you were not warned.

In the end, Mr Hunt, you cannot get away from this reality, eloquently stated by Richard Feynman: ‘For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.’

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD


1. The reply from the DH: for reply & my comment; for my first email to Jeremy Hunt
2. For my Submission to the Health Select Committee
3. Bogus bomb detector fraud
4. Questionable ‘evaluation’ of pilot
5. Pulse article ‘MPs to investigate GP practice boundaries’; I do not think they have actually investigated this issue. Nobody has called me, I have not seen it mentioned in the announcements from the Health Select Committee.

Department of Health response to my email to Jeremy Hunt: the smell of rotting fish


Yesterday I received the following email from the Department of Health. It alleges to be a reply to my email of 8/9/13 to Jeremy Hunt. It does not address any of the concerns I raised in that email. It is quite random, though it does contain some worrying messages, no doubt unintentionally.


Dear Dr Farrelly,

Thank you for your correspondence of 8 September about the pilot scheme to remove GP boundaries in six primary care trust (PCT) areas.  I have been asked to reply.

The purpose of the piloting arrangements was to trial the scheme with a limited number of practices in a limited number of PCT areas, the aim being to test whether these arrangements still provided patients with the best possible primary medical services.

Where a patient chose to register with a GP away from the area in which they lived, any urgent or immediate care was be the responsibility of the PCT for the area where the patient lived.  When registering, it was made clear to patients that they may be contacted to discuss their experience of being registered with a GP practice under these arrangements for the purposes of evaluating the arrangements.  Participating practices and PCTs were also interviewed.  An evaluation report has now been received by NHS England and is receiving consideration.  Following that consideration, a decision will be taken on whether to extend the arrangements across England.

I hope this reply is helpful.

Yours sincerely,

Patrick Driscoll
Ministerial Correspondence and Public Enquiries
Department of Health


I will be sending another email to Jeremy Hunt. In the meantime, it is worth noting that the DH official says that an evaluation has been carried out and the results sent to NHS England and is receiving consideration. Now this is surprising because the DH announced a year ago that the pilot would be extended by six months due to the chaotic first six months of the pilot. This would have meant that the pilot would have ended now, in September 2013. At this point, now in September, the evaluation could have been carried out. Instead we are told it has already been carried out. I smell the stink of rotting fish.

Another worrying message is this: the evaluation has looked at the experience of the (very few) patients who have participated in the pilot. Now of course they will say it suited them down to the ground. Practices will have been interviewed about their experience. I wonder what questions they were asked. PCTs have been interviewed: now this I very seriously doubt since PCTs disbanded in April 2013. And did they interview Tower Hamlets PCT and City & Hackney PCT, and ask them why they boycotted the pilot?

Worst of all is the fact that the evaluation is a sham as it does not evaluate the policy itself; the methodology itself is rigged to give them the outcome they wish, and to hide the very real problems that beset this brain damaged policy.

Shame on you Department of Health, shame on you Coalition Government.

‘If you want to sell a lie, get the press to sell it for you…’


Yesterday evening, after working all day to catch up on the infinite amount of backlog, my wife and I went to see the film Argo. At one point in the film, one character begins a sentence, ‘If you want to sell a lie….’ which is then finished by another character, ‘get the press to sell it for you.’

This seems to me to sum up well the role of the Department of Health Mediacentre during ‘selling’ of the Health and Social Care Bill.

More specifically, it is at the centre of the ‘selling’ of the policy to abolish GP practice boundaries. I used to think the politicians involved and the Department of Health were just remarkably stupid. I have now come around to the view that they are not stupid, they are carrying out a deception. What they really want is to deregulate English general practice, to make it boundary-free.

Why? Ask Virgin Care, KPMG, and McKinsey.

For examples of what I mean, read my article on Andy Burnham’s visit to the King’s Fund (and the blog post providing notes to this article), and my article about the press’s striking compliance with Department of Health’s Media Centre.

Message for GPs: Consider signing petition for Health Select Committee about GP boundaries


The Coalition Government is clearly intent on abolishing on GP practice boundaries: in their Interim Review they recently listed the GP boundary-free pilot as one of three areas that showed that they had ‘Improved the NHS’, by

allowing patients in six trial primary care trusts to register or receive a consultation with a GP practice of their choice. (page 24)

This is a most misleading claim: in reality 2 of the 6 PCTs have boycotted the pilot; of 345 GP practices in these PCTs, 42 practices have opted in to the pilot; at a recent count, 514 patients had registered with a practice, more than half in the London Borough of Westminster. These are small numbers. The DH and Government say they are going to ‘independently evaluate’ this pilot, but I fear that this will mean merely asking those (few) patients who registered with a practice how they found the experience. Of course, they will say they liked the opportunity to choose a practice near work, etc. The evaluation will almost certainly not evaluate or comment on the merits of the policy as a whole.

What can GPs do? I have written a series of articles for Pulse on this issue, and the 6th article addressed this question.

One thing we can do is to put pressure on the Health Select Committee to scrutinise this policy carefully. This would shine a light on the policy, the way it has been promoted with groundless and bogus claims, the way the public and Parliament have been misled, the way in which it will harm primary care in England.

If you are a GP, please sign the petition calling on the Health Select Committee to investigate the policy.


GPs refusing to extend their practice boundaries, from Pulse


Pulse has published an article on the resistance by GPs to extend their practice boundaries. I have posted the following comment to this article:

When a practice decides on its practice boundaries, it needs to be clear about the ecology of the practice’s functioning. What are the outer limits in allowing the practice to deliver good quality primary care, in an efficient, cost effective, and safe way? This should be the prime, and perhaps only, consideration.

GPs should resist firmly policies that undermine the ecology of good quality British general practice.

The policy to abolish GP practice boundaries is, when you scratch the surface, a hollow shell, an illusion, which will introduce all sorts of problems and give only a limited number of resourceful individuals ‘choice’.

If this policy was a financial product, it would be charged with gross mis-selling.

It is very important in the coming months that the GP community become more resolute and clear about this, and refuse to implement changes which will cause the service to malfunction. It is important that this issue becomes more public, and that mainstream journalists gain an understanding of how general practice functions. At present, they rely on press releases from the Department of Health’s media centre.


For a series of posts on the stupidity of this policy, click here

14. How can they be so stupid? The Plot Against the NHS


[This is the 14th in a series of 14 posts. I suggest you scroll down and start with Number 1]

The Plot Against the NHS is a book by Colin Leys and Stewart Player; I would recommend it, read it and judge for yourself.

Briefly, their thesis is that a ‘concordat’ was negotiated in 2000 by the Independent Healthcare Association with Tony Blair’s second Secretary of State for Health, Alan Milburn. ‘The Association’s leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, “to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers.”‘ (page 1)

The authors document the steps that were taken to further this aim. They call it a plot because it was covert, never made explicit, never debated. ‘Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage.’ (2)

Some excerpts:

‘So in spite of it great popularity Britain’s most famous postwar oscial achevement was unravelled through a series of step-by-step ‘reforms’ each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn the health care back into a commodity and a source of profit.’ (5)

‘Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘speacil advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Select Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.’ (5)

‘Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.’ (5-6)


These are just a few excerpts. I have bought and read the book. To me it helps make sense of DOH behaviours which are otherwise mind-bogglingly stupid.

If you understand the ‘Choose your GP’ policy as aiming to de-regulate English general practice and open it up to for-profit companies, then it is rather clever, not stupid. But it does rely on the public being duped, and not seeing through the duplicity and deception; and the journalists, and the GPs, and other health professionals.

11. How can they be so stupid? Cognitive Muddle


At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.

It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’

So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’

Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.

Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.


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