It is now crystal clear: the Choose your GP Pilot ‘independent evaluation’ in no way evaluates the actual policy

12/04/2014

Yesterday the practice manager of a large Tower Hamlets practice (and CCG Board member) and I went to meet with Professor Nicholas Mays and two other authors of the Evaluation of the choice of GP practice, 2012-13 at the London School of Hygiene and Tropical Medicine.

We outlined the reasons why abandoning practice boundaries in Tower Hamlets would not be in the interests of our aim to provide good quality primary care services to our local communities. Quite to the contrary, why it would be harmful and destabilising.

We had an interesting conversation about the pilot, about the various competing aims, about unintended consequences, about politicians, and about pilots.

I believe their report is well written and contains a number of important points, and they have done a serious piece of work. But they were clear that their evaluation only evaluates the pilot, and not the policy. The pilot had small number of patients and in no way ‘tested’ the policy; in fact, the sorts of risks I have highlighted in my Submission to the Health Select Committee are not revealed by the pilot, they are hidden. (I expressed these concerns in an article for Pulse in December 2012.)

It is as though you invited smokers over the age of 70 to meet you at the top of a tall hill, and you asked them if they liked smoking and if it had impacted negatively on their health. It is likely that they would say that they enjoyed smoking, and it caused them no problems (hence their age and ability to get up the hill). You might conclude that smoking was a harmless pleasure.

 


On recognising and naming MOOspeak from @Dhgovuk & @DeptHealthPress

19/01/2014

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’….


I smell a rat. Is Monitor working in the interests of patients or free market healthcare?

27/10/2013

I recently set up a Google news alert for articles on GP practice boundaries.

It threw this article up this morning.

“Monitor senior policy adviser Paul Dinkin, the man heading its primary care consultation, said his initial conclusion was that Monitor would play a major part in primary care.”

“Mr Dinkin said his review was looking at barriers to entry into general practice, such as practice boundaries and registered lists.”

“He said the BMA and the RCGP were wrong to say general practice needed more funding. ‘Our suspicion is not more money for the current model, but to rethink who does what.’”

And my suspicion is that Mr Dinkin does not know a great deal about the ecology of general practice, and that he has little interest in finding out.

Checking on the Monitor website, I found a Call for evidence on general practice services sector in England.  Issued on 1 July 2013, deadline for responses 1 August 2013. So I won’t be offering my views.

Who is Paul Dinkin and what is his background? I could find precious little online. Even on Monitor’s website there is no information.

Can we have some transparency, please?


My Submission to the Health Select Committee on GP practice boundaries

19/10/2013

[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.

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. 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

13/10/2013

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

Notes:

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.


NHS 111: If they tried, could they make the communication worse?

27/07/2013

We recently received a communication from NHS 111 about a telephone encounter with one of our patients.

I have removed any identifying details, and I suggest you read it. This is supposed to let us, his GPs, know about the conversation.

If this were a parody, we would say it was over the top.

I actually spoke with this patient soon after this NHS 111 conversation. She/he was on a phone list, waiting for me to return her/his call. She/he had rung NHS 111 to ask the significance of a blood result. It would have been wiser just to wait for me to ring to discuss the result.

That this national programme should have planned for such a shockingly opaque format for communications is very very worrying.

Whoever you are, please go back to the drawing board.


Warning to Health Select Committee on a policy damaging to general practice, from a whistleblower

06/05/2013

I wrote to you several months ago to check if you would be the appropriate body to deal with my concerns about a Government health policy. Two of your members kindly responded and said that it did seem appropriate for your committee. So I am now writing to ask you to look into the Government proposal to abolish GP practice boundaries.

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.

 

 

 


Will the real Neal Bacon please stand up?

09/03/2013

I had not heard of this man until yesterday. There has been some Twitter activity about him today, much of it raising questions. I followed some of the links.

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.

 

 

 


Letter from a mum with a reason to stop privatisation NHS

06/03/2013

I received this email from Linda via 38 Degrees; it is self-explanatory. Please sign the petition if you have not already done so.

 

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


12. How can they be so stupid? Brain damage

05/06/2012

While on holiday recently I read a book on the neuroscience of pleasure (David Linden, The Compass of Pleasure). The idea came to me that in some sense the policy to abolish practice boundaries and extend patient choice is actually ‘brain damaged’.

In this sense: the book discusses the way in which various pleasures (sex, certain foods, drugs, behaviours like gambling) activate discrete parts of our brains, which we then experience as pleasurable. The author highlights situations where, under the influence of certain pleasurable experiences (such as falling in love) there is a distortion of our critical faculties, a ‘deactivation of the prefontal cortex’, the judgement, planning, and evaluation centre. Money, cocaine, heroin activate these pleasure centres.

It occurred to me that possibly the thought of choice, the promise of choice, somehow activated the pleasure centres, and led to a deactivation of the prefrontal cortex, a distortion of our critical faculties.

This is perhaps just a metaphor. But it certainly seems to me that certain policies from the DOH appear to be ‘brain damaged’, that is to say that important thinking steps are simply left out.


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