My submission to the Listening Exercise on choice & competition

I am a GP in Tower Hamlets; my wife and I took over a singlehanded practice as a jobshare 20 years ago. We now have 2 part-time GP colleagues, and a list size of 3,520. I am sceptical about this exercise as I do not believe the people in power will use this feedback in any significant way. I say this because I believe they have their minds made up and will do what they can to proceed with their plans unchanged. This ‘pause to listen’ is largely a PR exercise. Also: the previous government established a ‘consultation’ about the ‘Choose Your GP Practice’; the conclusion after the consultation, issued a few months after the present coalition government took over, changed absolutely nothing. They used what they wished to back their plan, and ignored the rest.

But it is important to speak out, so here goes. Competition: for several years the Department of Health (DH) has trumpeted competition as a way of improving primary care (=general practice). I must say that in 20 years I have never felt in competition with my GP colleagues in Tower Hamlets. Not even for 5 minutes. If we do a good job, if we aim for good quality, it is because we want to provide a good service, we want to be up-to-date with our practice, it is because we take pride in our work. A few days ago Stephen Dorrell was quoted as saying “The idea there is no competition in the NHS is just bonkers. There are few more competitive groups of people than good doctors. They compete and that improves the care of patients.” I don’t know what he means by this; it does not ring true for me. I would recommend the writings of the American surgeon Atul Gawande; these are thoughtful accounts of the complexity of providing good quality humane care to sick people. What makes doctors better, is not ‘competition’ with each other (in fact, collaboration between professionals is a very important ingredient).

A few years ago a practice in Tower Hamlets became vacant through the retirement of the incumbent GPs. The practice was put out to tender under the present rules; two local Tower Hamlets practices put in bids, as did Atos Healthcare, a private multinational. Atos won the bid as they had underbid the local bids. At the time I wondered if they would be able to provide good quality general practice. From the stories I have heard, they were not. They scored at the bottom end on a number of measures when compared to other Tower Hamlets practices. Did the people who champion competition come to Tower Hamlets and observe this, have they learned a lesson from this? The local planners have learned something, but the Andrew Lansleys and DH people have not. You can read about this story at this link:

One particular issue that has vexed me is that of GP practice boundaries. When my wife and I were interviewed in 1991 (please note that it was the GPs who were interviewed in 1991, not some men in suits from Atos who were not doctors as was the case outlined above; when Atos were awarded the contract they still did not have the doctors who would actually deliver the service identified; I know because they later tried to recruit GPs and sent me a job application), we were asked what we were going to do about the ‘outliers’ (the patients who lived outside the practice area). This because in 1991 it was thought to be bad practice to have patients living at a distance from the practice. So we have been quite firm about our practice area; when people move outside the area, we ask them to register with a local GP. They are often reluctant to do so but, with an explanation, they understand the rationale. We have in essence carried out a pilot study of this issue over 20 years and our experience has been that the further away a patient lives, the worse the care they receive, and the more complex it is for the practice to deliver that care. In some cases it is unsafe. So when Andy Burnham proposed in 2009 (after being chided by Andrew Lansley who was then in opposition) that New Labour would abolish practice boundaries within a year, I was horrified. It seemed a parody; if there was a measure that would undermine care, stretch resources, and be unworkable, this was it. And the government was behind it, and the DH. [see my email exchange with ‘Andrew Lansley’; & The King’s Fund]

And this raises the issue of choice. Choice is the (stated) rationale behind this proposal. Choice seems to have a hypnotic quality: you say ‘choice’ and people seem to go into trance, and switch off their critical faculties. With reference to the abolishing of GP boundaries, when you will (theoretically) be able to register with the practice of your choice anywhere in England, think about this for a moment. Let’s say you know of a good practice 5 miles down the road from you (or even 20 miles or 100 miles); you must understand that this practice is currently working at full capacity or close to it. They do not have significant space for more patients; sure, they might be able to expand a bit, take on a few more doctors, build an extension, but they will have a limit. And besides, if they grow significantly, they will not longer be the practice they were before. And if you were hoping to see Dr Special, well Dr Special is already fully booked as it is today. How is she or he to have the time to make their skills available to you (and all the others like you who wish to ‘choose’ this doctor)? It is a mirage, a con, a scam. There are some who say that in fact the (unstated) aim of this policy is to open the door to providers on the model of American HMOs (health maintenance organisations; for further information see Wikipedia).

There is a very major problem in this whole debate, with all these issues (and they are multiple, and complex). And that is ‘methodology’. The method that seems to prevail at the moment is to take an ‘idea’, and then try to implement it without actually taking into account the most basic practical issues. So when Andrew Lansley tells you that there will be no decisions made without you, ask yourself just what does this actually mean and then try to model it, think of how it is going to work (along with all the other processes that have to work alongside it).

So what do we need instead? A brief sketch of my thoughts. We need to ask the question: what is needed? what do I want? what is essential? in the health service of this country. Then we have to ask: ok, what is needed in order to provide this? What are the structures, processes needed? What are the different possible ways of doing this, how would they work? What would they cost? What would be the unintended consequences? How would we know if it was working? How would we know if it was not working? We really need to move from the level of the abstract (choice, modernisation, reform…), to the concrete. And honesty, transparency, and an evidence-based approach are necessary. That’s it from me.

If you want further details, see

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