In January 2011 I began emailing MPs, one letter at a time (all the A’s, then the B’s, etc); & I copied the health ministers in as well. I then received an email from the DoH; a long disquisition on the White Paper, and the Bill which intended to ‘modernise’ the NHS. It said nothing whatsoever about practice boundaries. So I emailed the ministers, saying, among other things, this: ‘…your response is not really a response to my concerns at all. It is as though I had asked how to get to Bristol
from London by train and you had sent me a recipe for a cheese omelette.’
A few hours later I received this email:
Dear Dr Farrelly,
Thank you for your email of 31 January to Anne Milton about GP practice boundaries. I have been asked to reply.
The Government’s proposals for greater choice of GP practice are designed to reflect the central importance of general practice in providing continuity of care for those on their registered lists. The Department of Health knows that the majority of people are happy or very happy with their local GP practice and with the continuity of care that it provides. But the Department also knows that a significant minority have no choice but to register with a practice that they then rarely use because of difficulties of access, or because it does not provide a responsive service. Some of these people rely instead on using a mix of Accident and Emergency services, walk-in centres and other urgent care services. The Department’s aim is to ensure that everyone is able to register with a practice that provides genuine continuity of care.
The Department does not envisage that many patients will want to want to choose a GP practice a long way from where they live. There will clearly be many cases, particularly for people with complex health problems, where it makes obvious sense to choose a nearby GP practice. The Government thinks it wrong, however, to prevent people from registering with a practice (for example, one near to their place of work) where they have made an informed decision that this will provide the best and most responsive service for them.
On 4 March 2010, the Department of Health initiated a consultation to seek people’s views on proposals to abolish GP practice boundaries so that people can register with a GP practice of their choice. The consultation closed on 2 July and attracted over 5,000 responses from members of the public and clinicians, which shows how important an issue this is to so many people, patients and NHS staff.
The responses show that over three-quarters of the public want to be able to choose their GP practice and do not want this ability constrained by practice boundaries. Many GPs and NHS colleagues have raised issues about how opening up choice will work in practice, and the Department of Health is working through these issues with professional and patient groups and with the NHS. The Department published a summary of the responses on 18 October 2010, which is available on its website at:
The Department plans to set out a more detailed plan of action shortly that will look at the arrangements that the NHS will need to put in place over then next year. The Government is confident, however, that it can do this in a way that not only preserves the strengths of general practice and registered lists, but enables everyone (not just the majority) to benefit from these strengths.
I hope this reply is helpful.
My Response (copied to the health ministers, and members of the Health Select Committee):
Thank you for your response to my concerns. I would have answered sooner but have had to keep up with the day/evening/weekend job. I am afraid that you are up against a technical problem which cannot be eliminated by wishful thinking or sound bites. By ‘technical’ I mean things like gravity, not being able to be in 2 places at the same time, the fact that it takes time to get from A to B, that there are limits to how many travellers can (safely) fit on a plane, that if you try to walk across the Channel to get to France you will sink in the water. Your bosses and the politicians have just ignored the technical aspects of their proposal. Just as technical aspects were ignored or wished away in the invasion of Iraq. The trouble, in the real world, is that the technical persists.Would you want to work in a skyscaper that was built by dreamers? Perhaps designed by dreamers, yes, but then cleared by feet-on-the-ground structural engineers and built by professionals. May I suggest you read The Checklist Manifesto by Atul Gawande (a surgeon); pages 70-1 if you are in a real hurry.
In 1991 when my wife and I were interviewed by a panel in order to take on the responsibility of our present practice, one of the questions we were asked was, ‘What are you going to do about the outliers on the list?’ Outliers were patients who lived outside the practice area (some at a fair distance). Because at that time it was felt that to have patients living at a distance from the practice was ‘poor practice’, that it led to poor care. This was for technical reasons. We explained how we would deal with
this. We had to write to a number of patients who lived at some distance from the practice and ask them to get a local GP. They would have preferred to stay on the list, for their own reasons, that would have been their ‘choice’. It took extra work to do this, why do it?
The technical aspects which pertained then have not changed, they are pretty much the same. You cannot escape from that, that’s just the way the world works. The Department of Health and politicians have alluded to practice areas as an outmoded irritation, ‘constraining choice’. I assure you, there are perfectly sound, practical, reasons for ‘practice boundaries’. I have learned this over my 20 years in Bow. I see it every day.
Why am I spending time on a Saturday night writing to you, spending time with this issue? I would much prefer to be reading a book, watching a film, seeing friends. I am spending time on this because there are real reasons why what your bosses and the politicians are planning will lead to an undermining of good quality British general practice. And this is tragic. If we end up, 10 years from now, with a US-like model of primary care, that will be an incredibly retrograde step.
I do not have the time right now to respond to each of the points in your email. I will do so when I have time. I am not persuaded by your arguments. I certainly accept that we should aspire to providing good quality general practice to the whole population, but your bosses’ plan will not achieve this. The so-called Consultation which you allude to I view as a dishonest PR exercise. I hope to get the time to show why. Perhaps check my blog in a month or so.
Perhaps you truly believe what ‘The Department’ are doing. It may be that you think it is a bit crazy, but you have to pay the mortgage. I would not blame you if that is your position.