We’ve been expecting this.

It’s Monday morning, I’m on call, and we are — as usual — a touch light on doctors. One colleague is consulting in addition to me, and a locum is booked to come in at 11am, though it’s not clear yet whether he will do any visits or scripts. At 8.50am a call for an immediate visit comes through, and it is all I can do not to say ‘I told you so’.

I establish that Alfie’s dyspnoea is not such as to justify a blue-light ambulance but is too serious to wait till later in the morning. My colleague assures me that she can deal with her surgery, probably the bulk of my surgery, phone calls, enquiries, immediate scripts, immediate collapses in the waiting room and immediate everything else, and I head out into the freezing sleet.

It takes me 40 minutes to get to Alfie. Partly, this is because I have to negotiate a road junction that is so notorious that it has frequently been a topic for debate in Parliament. But the main reason is because Alfie lives absolutely miles outside the practice area, and has done so for years. I pass five surgeries on my way, including the excellent practice opposite Alfie’s house.

When I get there, Alfie is in extremis with an exacerbation of COPD, and his daughter, Jane, who has learning difficulties and asthma, is crying.

‘He didn’t want to call you — said it was too far for you to come, doctor,’ she says. I wait with Alfie, and encourage him to use his oxygen while the ambulance comes. Then I get on to social services to arrange Jane’s care for the next few days. By the time I get back to the practice there are two complaints pending, 14 people are still to be seen, and my normally serene colleague is close to tears.

This morning was always going to happen. This is why I have been pushing and pushing in meetings for us to encourage Alfie and Jane to register locally. Not only has a single visit seriously impaired the care we can offer to other patients this morning, never mind causing substantial stress; Alfie’s care has also been affected by the distance he lives from the surgery, since he has been reluctant to call when he should have done so.

Today I am really not interested in the sentimental view of one colleague that Alfie should stay on our list as he has been with us for so long and he is frail. That is exactly why he would be better off with the practice across the road from his home. Nor am I inclined to ‘be flexible’, as the health authority suggests; it is only worried about the local press. We have practice boundaries for a reason, and this morning is it.

Flora Tristan is an inner-city GP

Summary:

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. Who am I and why am I campaigning against this policy? I am a GP in Tower Hamlets. I have worked in our practice for 22 years. I was the medical director of the Tower Hamlets out of hours GP co-operative from 1997 to 2004.

I feel very fortunate and privileged to be working as a GP. Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

As GPs we serve a local community. Over the years, in our practice, we have had lots of experience of looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney. 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. (Examples provided in links, see below).

So we are firm with patients about registering with a local GP.

When in 2009 politicians began to say that they wished to abolish practice boundaries, I was bewildered.

2. There are two main reasons why this proposal makes no sense: one, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; two, because GPs are all currently working at full 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.

So there is a very serious design fault at the heart of this policy. For the past 2 years I have been blogging, and writing to MPs, to Ministers, to journalists to draw attention to the problems inherent in this policy.

Last Autumn I wrote 6 articles for Pulse on this issue.

These articles are also published on a separate blog.

3. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But I now think 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 (2) 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 below).

4. 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 this). 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).

5. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice, 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 (3).

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?

6. The DH agreed with the GPC to hold a pilot around this policy. 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.” 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). What they also failed to say was that 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.

This ‘pilot’ in no true way tests the 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, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

7. 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.

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.

8. 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.

9. 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.

10. I am writing as what some might call a ‘whistleblower’. That a busy GP should have to spend all this time in trying to get this message through to the politicians seems to me absurd. I am writing in the hope that you will listen and scrutinise this policy. But I am aware that there are many reasons why you as a committee might wish avoid this.

I am also writing so at least at a future date, when the inevitable problems surface, that you will not be able to say ‘Nobody warned us.’

Yours sincerely,

George Farrelly

The Tredegar Practice 35 St Stephens Road London E3 5JD

*

Backing documentation

(Numbering corresponds to the paragraph numbering above)

2.. Looking after patients at a distance from the practice does not work and it at times dangerous:

Blog posts by me.

3. a. The narrative: the mainstream press has so far largely just reproduced what the Department of Health Mediacentre have told them in the form of press releases. There have been three main press releases, and corresponding articles in various media. Analysis of these articles shows that mainstream journalists for the most part do not understand how general practice works, and that they have uncritically taken the DH formulations and promises as fact, when in fact they often do not make sense.

 See my post.

In time, the mainstream press may well wake up and look into this issue.

b. The problem of capacity:

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 is to shrink our practice area further a few months ago. So there is no way we could cope with an influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised), we are drowning as it is.

I came across an example which illustrates this problem recently. 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 currently registered patients, all of whom reside within their practice boundary.

Another example which illustrates this in a farcical way. The DH chose City and Hackney as one of their pilot sites. The City 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. 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. 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.

See my article.

4. On Burnham visit to King’s Fund, see my post.

5. On Government ‘consultation’, see my post.

6. On the Choice of GP pilot, see my post.

I am a GP in Tower Hamlets, one of the sites chosen for this pilot. What the Department of Health is not telling you is that two of the 6 sites above (Tower Hamlets and City and Hackney) have refused to take part in this pilot in order to protect the local health economy and services to our local population.

The proposed policy to abolish GP practice boundaries is deeply flawed, but the Department will not tell you that.

For more information, see www.gpboundaries.org

*

I checked this afternoon, and noticed that my comment (which I thought had been accepted on 31/3/13) was missing. There are in fact no comments to this page. So I have tried again. My Comment on Choices website but somehow feel that it won’t be visible, ever, to anyone else.

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.

Mile End Hospital

Bancroft Road

London E1 4DG

Jim Fitzpatrick MP

Rushanara Ali MP

1^st March 2013

Dear Jim and Rushanara,

Re: Section 75 Regulations and EDM 1104 (Early Day Motion)

We are extremely concerned about the regulations to bring into effect Section 75 of the Health and Social Care Act.

As commissioners we are determined to use all of the tools at our disposal to deliver the highest quality services for our patients and the people of Tower Hamlets.  To do this, we need to be able to commission integrated services which place the patient in control and provide a seamless passage across health and social care and through different health services.

Our view is that clinical commissioners must be provided with the freedom to use the full range of procurement tools including integration, collaboration, innovation pilots and a variety of competitive tendering mechanisms where appropriate. These must be based on achieving the highest quality and best value for patient outcomes rather than price alone, and give appropriate weighting to delivering the best care.  To do this we need to be free to choose what the most appropriate tool for any given situation is. Our concern is that the regulations laid under Section 75 of the Health and Social Care Act will be interpreted in a way that will obligate commissioners to carry out virtually all commissioning through competitive tendering.  This may negatively affect the way that seamless care can be delivered.

It is essential that CCGs are given greater freedom to choose when and how to procure new services and that the risk of referral to Monitor or the courts does not place a chilling effect on commissioners’ ability to take a more inclusive route if that is what they feel is best for patients, especially in relation to the care of complex patients, where services may be best provided by a small number of connected providers.

We all know that we face massive financial challenges in the NHS combined with managing a new system that has separated Primary (General Practice), Secondary (Hospitals) and Tertiary (Specialist) commissioning.

We do not underestimate this challenge and are determined to provide a high quality service for all our patients. Restricting our options will reduce our ability to provide the best for our patients and make it so much more difficult to manage the financial challenges.

I hope you feel able to support EDM 1104, which calls for a full debate on the issues raised by the Statutory Instruments laid under Section 75 of the Health and Social Care Act.

Best wishes

Dr Sam Everington

Chair

NHS Tower Hamlets CCG

There is enough to raise questions about his credibility, and ask for some clarification.

His blog claims he was a ‘nephrologist’, Harvard and Oxford trained. I would like to know what this means. I would like a list of the jobs he has done. Does he have MRCP? How high up the training ladder did he go? According to the GMC site, he is   a registered doctor, fully registered in 1991, but not on the Specialist Register. So is he misrepresenting himself?

I came across this blog entry from 2008. (This is what sent me to the GMC; you can check his registration, just enter name and surname).

And then this helpful page from Dr Rita Pal.

And then, ironically, given his enthusiasm for patients rating their doctors, this page where patients rated him 2.2 out of 5. But God only knows what that means.

Neil Bacon is an entrepreneur (says so on his blog; the Biography page is so far empty so I don’t know what experience he has with primary care). He is selling a product, so obviously he will promote himself and his product.

This is what I posted on his blog piece:

I have decided to try to write brief, daily (or almost daily) posts about what happens in my primary care day.

Friday is my day off. But I have been coming into work on Fridays since 2006 when we switched to a new computer system and I started coming in on Fridays in order to do the extra work involved in making the transition.

This morning I did some desk work and then went to a sheltered accommodation block in order to take blood from one patient I had seen earlier in the week, and in order to review another patient in the same block. While I was there, the ‘scheme manager’ (previously called the ‘warden’) asked me to see another of our patients. And we spoke about another who concerned her.

And then she said how much she appreciated the service our practice provided. I thanked her for her positive feedback, and said we were doing our job. Then she said that all the negative press about the NHS and GPs really frustrated her.

Earlier this morning I had seen a post by Roy Lilley, which I would recommend. He has been attending the Nuffield Trust summit on the question ‘Is the NHS Fit for Purpose’.

Walking back to the surgery I daydreamed: ‘Is the Department of Health fit for purpose? Are the Health Ministers fit for purpose? Is a methodology that involves (willful) ignorance, misrepresentation, PR, and lies a methodology that is “fit for purpose”?’ And I was thinking of this.

A thought: if you want health professionals to do a good job, it is important that they feel positive, that they feel proud about what they do. And they need enough time to do the job. (And a few other ingredients: I’m not listing them all tonight).

Further work today: teaching medical students, seeing patients. Now it is 8pm on my day off and I am going on 2 more visits, both in another home, with higher dependency.

One comment on my particular issue, that of GP practice boundaries which the DH and Government want to abolish: I was able to see three patients this morning quite efficiently, in the same block. I got there on foot. Tonight I am seeing 2 patients at essentially the same address. I will ride my bike to get there, on my way home. These two homes are within our practice geographical area, within reach of the practice. Without a limited geographical area we would not be able to visit these patients efficiently, or at all.

What would the scheme manager say then?

(this was a bit longer than I had intended)

Dear George,

My name is Linda. I’m a long-standing 38 Degrees member, and I’m sending this email because I know first hand why it matters so much to stop the privatisation of our NHS.

On Friday afternoon, I will deliver a copy of the petition against NHS privatisation – which you and I have both signed – to the Health Minister.

When I hand the petition over, I will tell the Health Minister about what happened to my baby. He died when he was just seven weeks old whilst receiving care from my GP out-of-hours service – which had been recently privatised.

Can you help me have as many names as possible to hand in on Friday afternoon, by forwarding this email to as many of your friends as possible asking them to sign it too?

They can sign by simply clicking this link and adding their names:
https://secure.38degrees.org.uk/nhs-section75

Last week was a hard one for me. It was the inquest into the death of my baby son, Axel. He died last November from pneumonia. His illness went untreated despite repeated calls and visits over the course of five days to my NHS out-of-hours doctors’ service, which had been recently privatised.

I feel the inquest left many of the biggest questions unanswered – like what role NHS privatisation may have played in the mistakes which led to the death of my baby boy.

After hearing evidence of how that private health contractor had acted, I feel determined to do all I can to stop further privatisation of our NHS. That’s why I’ve decided to get more involved with 38 Degrees, and why I’m going to see the Health Minister this Friday. I’d really appreciate it you could help me get more names on the petition before I meet him.

Please, pass this email on, and ask your friends to sign the petition for this important campaign:
https://secure.38degrees.org.uk/nhs-section75

We had a bit of a breakthrough with this campaign yesterday. The government announced that because of all the pressure they would withdraw and rewrite their NHS privatisation regulations. The petition which I’d signed, along with 240,000 other 38 Degrees members, was mentioned in Parliament. That shows we can make a difference.

But I remember, as I’m sure that you will, that when the government promises to rewrite a plan, that doesn’t necessarily mean that the new version will be any better than the old one. We need to make sure they genuinely drop any attempt to force GPs to open up services to privatisation.

I would love to have as many signatures as possible by Friday afternoon when I visit the Health Minister. Please pass this message on to anyone you think might be interested: https://secure.38degrees.org.uk/nhs-section75

Thank you.

Linda

PS: You can read more about what happened to my baby in this piece in the Guardian: http://www.guardian.co.uk/society/2013/mar/02/nhs-commercialisation-bereaved-mother-fight But please sign the petition first: https://secure.38degrees.org.uk/nhs-section75

PPS: This email has been sent from Linda Peanberg King using the 38 Degrees system. Your email has not been shared with anyone else.

PPPS: In case you missed it, below is the 38 Degrees email we sent out last week at the start of this campaign:

A new fight over NHS privatisation has just begun. Jeremy Hunt is trying to use new powers, hidden within last year’s controversial NHS laws, to force local GPs to privatise more health services. [1] This is one of the things we were afraid might happen – and now our worst fears are being confirmed. We need to do all we can to stop it.

Jeremy Hunt’s new privatisation plot is contained within “NHS competition regulations”. [2] Usually these kinds of rules get quickly rubber-stamped by Parliament. This time, we need to get MPs and Lords to stand up to Hunt and block his plans. [3]

It’s a long shot, but we have a chance of stopping these changes because Hunt is breaking promises made to MPs when NHS laws were voted through last year. [4] If we generate a huge, public outcry to put pressure on the politicians who clung on to those promises last time the government attacked our NHS, we can convince them to stop these new laws.

Sign the petition against Jeremy Hunt’s new NHS privatisation plan here – we’ve got just a couple of days before we’ll need to deliver it:
https://secure.38degrees.org.uk/nhs-section75

Hunt’s new regulations (Statutory Instrument 257 under Section 75 of the Health & Social Care Act 2012) are like a catalogue of our worst fears. [5] GPs would have to open up every part of local health services to private companies, whether or not it’s what they or local people want. It would speed up the break up of the NHS, giving profit-hungry companies new rights to muscle in.

Last year, the government promised it wouldn’t go as far as forcing privatisation on local health services. Lots of MPs and Lords said these promises convinced them to vote for the NHS law. Now, we need to go back to these same MPs and Lords, and tell them to find some backbone. If they really voted for the law because of those promises, now they’ve got no excuse not to put a stop to Hunt’s latest privatising move.

Let’s build a petition to hand in to each of the MPs and Lords who believed the government’s promises on privatisation:
https://secure.38degrees.org.uk/nhs-section75

All over the country, 38 Degrees members have been working together to convince their local NHS decision makers to do the right thing and limit privatisation in their area. Now, government is trying to take that power away from local doctors and the patients they serve.

This is going to be tough. It could be the start of the second round of the fight to protect everything that’s precious about the NHS. But it’s the right thing to do, because we know that when private companies move in, all too often it doesn’t end well for patients.

Sign the petition now:
https://secure.38degrees.org.uk/nhs-section75

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.