My email to NHS Medical Director at Department of Health May 2010



I am a GP in Tower Hamlets. Several weeks ago I received the booklet The NHS Quality, Innovation, Productivity and Prevention Challenge: an introduction for clinicians. I felt I needed to respond to this, and I sought your email address which you kindly provided.

I had mixed feelings on reading the booklet: on the one hand, relief that someone at the DOH wanted to look at the issue of quality, on the other hand anger because for some years we have been the victims of government and DOH-led initiatives which have had a direct effect of lowering quality. It may be that you and your colleagues are truly interested in quality, I hope so. But you need to know that it is likely that down the corridor from you (metaphorically speaking) there are others planning policies which will impact negatively.

There are numerous examples of the madness which is visited upon us. I will give you one. In brief it is this: the 2004 GP contract stipulates that we cannot cap our list size; we are required to register any patient living in our practice area. We can apply to close our lists; this requires approval by a panel; once closed, the PCT can withold enhanced services payments (because a practice with a closed list is in essence a ‘failing’ practice and therefore not fit to be providing enhanced services). We are advised that to apply to close our list is a last resort.

We are a small practice. We aim to provide good quality primary care. We have been in the practice for 19 years. Our patients value what we provide. They do not want us to expand beyond recognition, they do not want us to implode. A year ago we put our foot down: we would not go beyond 3,520 patients. We were upfront with the PCT. They advised us to reduce our practice area (this was the only mechanism by which we could ‘legally’ achieve our aim). But how do you adjust your practice area so that you can achieve a steady state of 3,520? I attach 3 documents which chart this particular issue: the email exchange I had with the LMC, and then PCT; the Tower Hamlets registration policy 4.09; a document I drafted in response to this registration policy. If you read these documents you will note that quality is an important ingredient which requires attention. (Incidentally, we do well in the MORI survey, we are considered one of the model practices in Tower Hamlets, so what I am writing is not sour grapes).

In November 2009 I was invited to a meeting at the PCT. I outlined the double bind that this policy puts us in; I told them it was bonkers; I acknowledged that they were caught in the middle, that their careers required that they implement what people at the top deem to be policy, that there does not seem to be a mechanism for feedback in all this (and you will know that feedback is a vital part of functioning systems). I told the PCT that I was not willing to die implementing a bonkers policy (I work a 60-70 hour week and I am techinically a part time GP). I said if they forced us to increase our list size that I would resign, but not before our patients became aware of the issues at hand and were able to communicate their feelings to the PCT and the press. The PCT had no response. They were shocked. We continue to be in breach of our contract. I happened to meet Andy Burnham when he came to Tower Hamlets recently: I told him we were in breach, that we were being asked to do something mad and that we had finally woken up and decided to resist. His expression was blank; he really does not understand what actually happens out here.

I could go on and on, there are other areas where stupidity (not quality) reigns. (The current, presumably to be shelved, ‘consultation’ on choosing your general pracgtice is another example of this). My message to you and your colleagues is don’t send me leaflets with rhetoric about quality if you are asking us to do things which undermine quality. The problem is not with one or two isolated areas. Shot through the policy making and implementation framework are weaknesses and flaws which inevitably lead to dysfunction. It is very demoralising. What keeps me going is that I value the work we do and the patients value it. I feel fortunate to be doing this work. But I am really fed up with the rhetoric and arrogance and ignorance of the politicians and faceless people at the DOH. I will continue to resist.

I do hope you and your colleagues are truly in pursuit of quality (and not just saving money); if so, I wish you well and would support your effort.

Best wishes,


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