I put a question mark after corporate lobbying simply because I have no direct proof myself of this activity. I am close to certain that this activity has taken place over time with respect to the issue of GP practice boundaries, and I think it is likely that this plays a central role in driving this policy. The politicians talk about patient choice, but underneath it all is really an aim to de-regulate English general practice and open it up in quite a new way to for profit companies.
How and why?
At present practices cover a limited geographical area. This limits the number of patients. Remove this factor, make registration free of geography, then it opens up an entirely different model which can be exploited by companies like Virgin Care.
These companies can set up medical centres in major cities, wherever is most profitable. They will attract a clientele of mobile, essentially healthy professional people. They will not have to deal with these patients when they are actually sick because they will be too unwell to travel to their centres; someone else will have to visit them. The elderly, people with chronic diseases, will remain registered with local GPs.
It will be convenient for the mobile and well, and profitable for the firms. But it will not deliver primary care in any real sense, and will in essence be a virtual asset stripping.
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.
At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.
It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’
So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’
Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.
Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.
If you are offered something attractive by someone, you naturally hope that it is what you are going to get. You hope it ‘will come true’, that it will not be illusory.
The property bubble and the disastrous crash in 2008 was at least in part built on ‘wishful thinking’. Bernie Madoff’s ponzi scheme went on as long as it did at least in part due to ‘wishful thinking’ on the part of his investors.
If Andrew Lansley is going to offer you choice, why turn him down?
‘I mean choice, at no cost, it can only be a good thing, right? We have the Department of Health’s assurance on this, right? I’ve read the leaflet, what’s not to love about it? Sure, I’ll go with choice, it’s a no brainer.’
The Oxford Dictionary of English has next to nothing for stupidity. For ‘stupid’: lacking intelligence or common sense; dazed and unable to think clearly: apprehension was numbing her brain and making her stupid
lacking intelligence: yes, this is relevant
lacking common sense: yes, definitely
dazed: they should be
unable to think clearly: yes, many examples of this
With the issue of GP practice boundaries, there is in general a very limited understanding about general practice actually works, about how good quality general practice works. Even our hospital doctor colleagues often do not understand how it works.
Good quality British general practice is a very complex technology which serves local communities in geographical areas. You need to have an understanding of this and how it works. Otherwise, you are ‘ignorant’.
A GP colleague of mine has been to a number of events organised by the Department of Health in recent months. She has been struck by how ignorant the people from the Department of Health are about how general practice works, how general practitioners work, how good quality British general practice works.
‘Wilful ignorance’: don’t confuse me with the facts.
The Government and Department of Health recently announced pilots for commuters to be able to able to register with GP practices near their place of work. Tower Hamlets, City and Hackney, and Westminster are amongst the pilot sites.
There was an article in Pulse this past week which quoted some of the misgivings of affected LMCs (Local Medical Committees).
I posted the following comment to the Pulse article (as well as the similar story in GP Online):
I have been thinking about this issue for some time now. I know that a minority of GPs are ‘excited’ by it, but I am not clear why. I practice in Tower Hamlets; when people move away, it becomes in many ways unworkable to continue to look after them as patients. This has been our experience. Yes, there are some groups of patients who need a workable solution: use a sensible methodology to find that solution, but be clear-headed and honest about the risks and problems.
I fear that this whole ‘Choice’ issue is just a Trojan horse. The Choice offered is an illusion, and hidden within this horse are all sorts of problems, unintended consequences, anomalies. I hope in the coming months this issue will be aired, the deceptions made clear. It is essentially a fraud. The ultimate aim (covert) is the de-regulation of English general practice. De-regulation in the sense that financial services were (under concerted pressure from lobbyists) de-regulated, leading to financial gains for some, but (undeclared) risks and subsequent losses for many clients. General practice without boundaries is, I think, the Holy Grail for some. But it won’t give us good quality, community based, integrated, family medicine. Indeed, it will undermine it.
This story will develop in the coming months, as the practicalities begin to bite.