My email to Health Select Committee on GP practice boundaries-Grotesque stupidity or deception?


Dear Health Select Committee Members,

Brief Summary: I am a GP; there are very significant problems with the policy of abolishing GP practice boundaries. Is this a matter for you; if not, why not, and who should concerns be addressed to? Is this an example of grotesque stupidity or deception? I am writing a series of articles for Pulse on this issue.

I have been a GP in Tower Hamlets for over 20 years. I was the Medical Director of the Tower Hamlets GP out of hours co-op from 1997 until 2004 when the PCT took over responsibility for out of hours cover. I know a fair amount about the practicalities of providing good quality general practice to local population.

Because we are a popular practice, when patients move away they often want to remain registered with us. This has given us, over the years, a lot of experience in looking after patients at a distance from the practice. And it is clear that it does not work: the greater the distance from the practice, the greater the barrier to care; it is inefficient, time consuming, and at times unsafe. That is why we insist that these patients register with a local GP. Here is an example of the problems that  arise.

This is just the tip of a very large iceberg. There are numerous other reasons why this does not work.

So it is very bewildering to us that politicians and (anonymous) policy makers at the DH should be backing this policy. I used to think it was just grotesque stupidity that drove this. But this just does not make sense, it does not add up. A more credible explanation is that there is a hidden agenda: the drive to abolish GP practice boundaries is not about giving patients choice (which it will not in fact do), but about freeing up (‘liberating’ to use Andrew Lansley’s language) English general practice to a different structure which will please Virgin Care and McKinsey but will actually destabilise and undermine good quality general practice, and introduce additional costs.

So either politicians and the DH are remarkably stupid (in which case they should not be in charge of this), or they are carrying out a deception on the English public (which is really quite shocking).

I am writing a series of articles for Pulse, a GP publication. As part of my research I want to find out what the Health Select Committee’s brief is. If what I am claiming has a solid basis (and I have evidence to support my claims), would this be in your remit? If it is not, why not? If it is not your remit, then who should GPs, and patients, address themselves if they find themselves sharing my misgivings?

Best wishes,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

“For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.” Richard Feynman, Physicist

cc to Health Editors at Guardian, Telegraph; Mirror; Daily Mail; Jennifer Dixon, Nuffield Trust; Clare Gerada, RCGP Chair

‘This is why practice boundaries exist’


An article [link below] appeared in the BMA News in January 2012 illustrating why, from a purely practical point of view, GP practice boundaries exist. I have blogged previously with examples from our own practice [link below].

The article makes a number of important points: looking after people at some distance from the practice is time consuming. Not only is it difficult to look after these individuals well and safely, but to do so will impact on the service as a whole (so the service and care to the local population is affected).

This is why practice boundaries exist    Click here

Examples of patient care at a distance    Click here



14. How can they be so stupid? The Plot Against the NHS


[This is the 14th in a series of 14 posts. I suggest you scroll down and start with Number 1]

The Plot Against the NHS is a book by Colin Leys and Stewart Player; I would recommend it, read it and judge for yourself.

Briefly, their thesis is that a ‘concordat’ was negotiated in 2000 by the Independent Healthcare Association with Tony Blair’s second Secretary of State for Health, Alan Milburn. ‘The Association’s leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, “to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers.”‘ (page 1)

The authors document the steps that were taken to further this aim. They call it a plot because it was covert, never made explicit, never debated. ‘Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage.’ (2)

Some excerpts:

‘So in spite of it great popularity Britain’s most famous postwar oscial achevement was unravelled through a series of step-by-step ‘reforms’ each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn the health care back into a commodity and a source of profit.’ (5)

‘Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘speacil advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Select Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.’ (5)

‘Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.’ (5-6)


These are just a few excerpts. I have bought and read the book. To me it helps make sense of DOH behaviours which are otherwise mind-bogglingly stupid.

If you understand the ‘Choose your GP’ policy as aiming to de-regulate English general practice and open it up to for-profit companies, then it is rather clever, not stupid. But it does rely on the public being duped, and not seeing through the duplicity and deception; and the journalists, and the GPs, and other health professionals.

13. How can they be so stupid? Corporate lobbying?


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.

12. How can they be so stupid? Brain damage


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.

11. How can they be so stupid? Cognitive Muddle


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.

10. How can they be so stupid? Wishful thinking….


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.’