I am a hardworking GP in Tower Hamlets. My aim is to try to provide good quality primary care services to the local population of Bow.
I am indignant: you politicians and your colleagues at the Department of Health are designing policies which make my job harder, if not impossible. You dress it all up with words like ‘Choice’, ‘modernisation’, ‘reform’: but much of it is really just ‘sabotage’.
I am indignant: you are using a very stupid methodology. You avoid looking at risk; in fact, Andrew Lansley has gone so far as to keep risk secret. And you just seem to accept this. Is this intelligent?
I have been running a protest blog for the past year, and writing to MPs, one letter at a time. Now is the turn of the L’s. I know there is a convention that you don’t deal with issues raised by people who are not your constituents. (Do you read newspaper articles by people who are not your constituents?). Consider me a lobbyist then. I am lobbying on behalf of good quality English general practice. Am I paid to do this? No, it costs me. Do I stand to gain financially? I don’t think so.
I am doing this because I am indignant. This email, my blog, my activity on Twitter, is my protest, my tent pitched in the square.
My protest, my focus has been primarily on the issue of GP practice boundaries.
All 3 main political parties are in favour of the policy of abolishing GP practice boundaries, and allowing people to choose their GP practice without the constraints of geography, anywhere inEngland. When I first heard this proposal over 2 years ago, I could not believe that anyone would propose such a thing, so mad did it seem.
I will be brief, and if you want additional information, go to my blog. See links below.
1. You would think that anyone drawing up a proposal to change the structure of general practice inEnglandwould do some sort of robust assessment (including risks, unintended consequences, etc.) before launching the policy in public. This is basic, I think you would agree. Yet for this policy, there is no evidence that the Conservatives, Labour, or the Liberal Democrats ever did a risk assessment. I emailed Andrew Lansley in March 2010 and with some difficulty extracted the evidence that they had not carried out any risk assessment or feasibility study. New Labour and Andy Burnham’s evidence lies in the Department of Health’s documentation surrounding the so-called ‘Consultation’ Choosing Your GP Practice, launched in March 2010. This documentation lacks any serious examination of risks and unintended consequences. The documentation is essentially a PR exercise designed to elicit a ‘Yes’ to the questionnaire, which politicians have since used as ‘evidence’ that the people of England want to be able to choose a GP practice anywhere in England. Indeed, on more than one occasion, Andy Burnham has said, ‘I can see no reason why people cannot register with the GP of their choice.’ Not even one reason: clearly, Andy Burnham, despite being Secretary of State for Health, had not done a risk assessment. And he continues to say this sort of thing, as recently as December 2012. I have asked the Liberal Democrats (more than once) for any evidence that they carried out a risk assessment; silence.
This sloppiness, recklessness, arrogance: it makes me indignant, very indignant.
2. Your policy promises to give the people of England greater choice, ‘real choice’ as Andy Burnham has said. This choice is really an illusion. What you must understand is that the vast majority of GP practices are currently working at full capacity. They do not have spare capacity to absorb significant additional numbers of patients. Your idea is that the popular, well-performing practices that offer a good service will attract patients from the poorly-performing practices. This will simply not work, not to any significant degree.
Indeed, there is a risk that local people will not be able to register with a local practice because people outside the practice area have taken up part of the limited capacity. So far from doctors competing with each other, we will have patients competing with each other for places in a desirable practice.
And if you force practices to register all comers (as is currently the case with the 2004 GP contract), then the standards will fall.
Politicians and the Department of Health simply do not seem to understand the reality of capacity, and its relation to quality. This is very basic. It is shocking that an organisation that is supposed to organise a National Health Service should be so stupid.
Put another way, it is essentially a zero sum game. For some there may be some scope for expansion, but this will have its limits. Perhaps you can understand this if you think of the game of musical chairs. There are a limited number of chairs, more or less enough for the English population. Your modelling appears to assume the chairs are unlimited.
3. Then there is the reality of how general practice works: it is a local technology. The service works for a local community, and has links and networks to local services. We have worked in our community for 21 years. When people move away, they try to remain registered with us; our experience over the years is that this does not work, and is at times unsafe. I give examples of this on the blog.
To actually restructure things so as to remove the locality-base means to destabilise how the system works: it leads the system to malfunction.
You think you are doing something good when in fact you will cause a system under a fair amount of strain to malfunction: you are unwittingly sabotaging primary care. And you call this ‘modernisation’.
This too makes me indignant.
4. Let me return to capacity and quality, which is another focus of my protest on the blog. The current rules on patient registration is that we should register anyone in our practice area who wishes to register with us (=patient choice). But we found that this would destroy us; so we decided, unilaterally, to refuse to do this. We keep our list size at about 3,520; as people leave the area and the list, we register new patients. We have been quite open with the PCT and the LMC. The reasons are documented on the blog. I wrote to the Department of Health about this, and met with the then GP ‘tsar’. He agreed with me that this was not a sustainable situation, and said this was not a national policy but a local mistaken application of a national policy. I did not think this was the case. I asked who was responsible for this policy. He did not know. He did not offer to find out.
The recently published guidance to PCTs on the implementation of the pilot for commuter patients in 3 English cities (Tower Hamlets is included in the pilot) reiterates this directive: what we are currently doing is prohibited. We would have to either have to take all comers or shut the list to everyone (with the permission of the PCT). The guidance says that otherwise patients get confused. In our experience, patients understand this entirely and are not confused by it.
This is a very stupid policy and we will continue to adopt a stance of civil disobedience, and protest against it.
This too makes me indignant.
5. So if abolishing practice boundaries is so stupid a policy, why are they doing it?
There is a hidden agenda. What I believe this is really about is the deregulation of English general practice, the marketisation of general practice. Whilst the Department of Health goes on and on about patient choice, the true incentive is this: by eliminating practice boundaries, it will allow for profit organisations to set up primary care centres which can register people regardless of where they live. These centres will have no commitment to a community, to a locality. They will be based in city centres and their patients will be the healthy and mobile. If these patients get sick and are unwell at home, the centres will not have to look after them because they will not be local, they will be at home. Someone else will have to provide care for them where they live. (See the Department of Health guidance document, section 6).
Abolishing practice boundaries will ‘liberate’ the NHS for these entrepreneurial groups. These will essentially be glorified walk in centres catering for the healthy.
This too makes me indignant.
6. The proposed policy to abolish GP practice boundaries is a relatively small part of the Health Bill, and not on most people’s radar. But for general practice it is a very important issue.
The opposition to the Health Bill is growing inexorably. Even Tories are worried about the fall out. Andrew Lansley and David Cameron say they are determined to soldier on.
Let me give you a warning from the front line. Much of this Bill is built on PR: Choice, Modernisation, Reform of the NHS. Whenever Andrew Lansley or David Cameron or Simon Burns are questioned about an aspect of the Bill, these words will be central in their answers.
But what lies underneath all this? My wife is a member of the Tower Hamlets CCG. She is committed to trying to commission good services for the people of Tower Hamlets, but she thinks the structure that Andrew Lansley has designed makes the project unworkable.
I have studied the practice boundary issue carefully. It is a scam. My suspicion is that other aspects of the Bill are also scams.
If you push this Bill through, which seems to be the likely outcome as I write, things will unravel. They will unravel because built into their design are flaws. If this Bill was a building, it would not stand up, it would collapse. If it was a bridge, the bridge would collapse. So things will begin to malfunction, and it will be clear to all of us that they are malfunctioning because of design faults which are your responsibility.
At that point, the penny will drop. People will realise that they have been had, that all the rhetoric was just PR, emperor’s new clothes. And there will be anger; and this anger will be directed, rightly, at you. The warning signs are there: you can choose to pay heed, or you can plough on.
Reflect on this statement by Richard Feynman, the physicist, which I have adopted as the motto for my blog: ‘For a successful technology reality must take precedence over public relations, for nature cannot be fooled.’
1. My email exchange with Andrew Lansley
2. The problem of patient registration policy, in a nutshell
3. Your Choice of GP: the problem in a nutshell
4. The problem of caring for patients at a distance; examples
5. Email exchange with an MP attracted by the idea of being able to choose a GP at a distance
6. Email exchanged with The King’s Fund on GP practice boundaries
7. Department of Health Choice of GP Practice – Guidance for PCTs Jan 2012
8. Department of Health’s ‘Consultation’ PR exercise Your GP Your Choice Your Say