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

05/06/2012

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

05/06/2012

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

05/06/2012

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….

05/06/2012

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.’


9. How can they be so stupid? Being duped…

05/06/2012

If there is a deception being carried out, then there have to be people being deceived, being duped.

If a politician promises something that he or she knows cannot be delivered, and a citizen believes this, then the citizen has been duped.

If a politician promises something thinking they can deliver it, and a citizen believes this, has the citizen been duped?

In the case of the GP boundary issue, I think it is likely there are some politicians who think it is perfectly practical (in which case they are stupid, and not participating themselves in a deception) and are unaware of the unintended consequences; if they promise their constituent to deliver this is the citizen being duped?

A concrete case: on 30 December 2011 (is there a significance in such a date) the Department of Health launched the ‘Choose Your GP’ pilot. Almost immediately a number of articles appeared in the online press (Telegraph, Express, Oxford Times, and others). These ‘articles’ were essentially all the same, they all repeated what the DOH ‘Media Centre’ told them. They all more or less lifted the text from the DOH webpage. The articles did not say ‘All this content is from the Department of Health as they are giving it out. I cannot guarantee the veracity or reasonableness of the content.’ Nor did any of the articles analyse what was being offered, ‘promised’. They just presented it. A citizen reading the article could be excused for thinking the content, the promises, were reasonable and achievable.

So in this case, the journalist is being duped, and in turn, unwittingly, is duping the public.

(I checked this with one of the journalists, and offered some additional information which critiqued the content of the DOH webpage; the journalist said that he/she had had to rely wholly on the DOH content; and had he/she been aware of what I had told him/her, he/she would have written a different story. There may be more on this in the future).

DOH ‘Media Centre’ Launch

Two examples (there are at least 5 others):

Oxford Times ‘article’

Express ‘article’


8. How can they be so stupid? Duplicity

05/06/2012

Duplicity:Oxford Dictionary of English: deceitfulness; archaic the state of being double.

Andrew Lansley gave a speech to the Royal College of General Practitioners’ annual conference in October 2011. I did not attend but fortunately the speech is available on video, as are the questions and answers after the speech. So I was able to listen to these. What he had to say about GP boundaries was actually not unreasonable, he seemed to have understood the problem (‘Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this.’; whatever was done had to work, they had to find ways that worked; ‘I’m not abolishing practice boundaries…’). But I was sceptical: let’s see what happens. A few weeks later the GPC signed a contract for 2012-13 which agreed to a pilot on GP practice boundaries, and for asking practices to create ‘outer practice boundaries’ which retained patients who moved from within the practice boundaries. This was not unreasonable, but I remained sceptical: how independent and probing would the ‘independent evaluation’ of the pilot be?

Then came the launch of the pilot, at the end of December 2011:

It allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

Health Secretary Andrew Lansley said:

‘Many patients are happy with their local GP practice, but a significant minority have problems registering with a practice of their choice. This pilot will mean patients taking part can access the high quality care they deserve in a place and at a time that suits them.

‘That’s why I believe patients should have the freedom to choose a GP practice that suits their lives, and not be restricted by geographical boundaries.’

He did not really believe what he said to the GPs in October. He was intelligent enough to know what sort of thing he had to say in order not to be eaten alive, but his intention was, and still is, to plough ahead with the abolition of practice boundaries. And this is how it was reported in the press.

In this sense, he is duplicitous, ‘double’, speaks with ‘a forked tongue’. Not to be trusted.

(For text of what he said to RCGP)


7. How can they be so stupid? Deception

05/06/2012

The Oxford Dictionary of English has very little: act of deceiving someone: obtaining property by deception

Wikipedia is much richer here:

“Deception, beguilement, deceit, bluff, mystification, bad faith, and subterfuge are acts to propagate beliefs that are not true, or not the whole truth (as in half-truths or omission). Deception can involve dissimulation, propaganda, and sleight of hand. It can employ distraction, camouflage or concealment. There is also self-deception as in bad faith.”

Yes, this is very helpful. I read this description, this list, and I think spontaneously of the New Labour Government’s so-called ‘Consultation’ on the issue of choice of GP, launched in March 2010. The documentation accompanying the ‘consultation’, and the ‘questionnaire’ were clearly designed to lead to a ‘yes’ vote. And then now, the Department of Health, and Lansley, use the ‘results’ of this ‘consultation’ as one of the main planks supporting their policy. I believe that this ‘consultation’ was quite misleading, an act of deception.

No doubt this will cause consternation in some quarters. Fine, read the documentation. Ask yourself this: is this balanced? what is the message? what are the omissions? what are the risks of this policy (hardly any mentioned)? are the questions in the questionnaire ‘leading’ ones? ask an (independent) expert in polling what they think of the format of the ‘questionnaire’.

To get a taster, read the patient leaflet. For the full document (the Questionnaire starts on page 45).

For full Wikipedia article on deception

Yes, I must add ‘bad faith’ to the original list.


6. How can they be so stupid? Stupidity-to different degrees, at times grotesque

05/06/2012

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

 


5. How can they be so stupid? Ignorance, wilful and unwilful

05/06/2012

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.


4. How can they be so stupid? Naivety

05/06/2012

We are all naive about some things, inevitably. If we are wise, we know when we are naive, when we are stupid we are unaware of our naivety and act as if we understand a situation. A recent experience of mine: my wife and I have been to the US on a holiday. We spent some time in different cities (Seattle, Vancouver, San Francisco, Brooklyn/NYC); now each city’s public transport city operated in a slightly different way. Tickets, free areas in some cases, how to pay, etc: we had to inform ourselves and understand the system if we were to minimise the cost and get to where we wanted to get. On arrival in each city, we were ‘naive’, inexperienced. Had we assumed the system would operate the same way as London Transport, we would have been ‘stupid’.

Oxford Dictionary of English: naive: adjective, showing a lack of experience, wisdom, or judgement: the rather naive young man had been totally misled.

A patient of mine who had moved to Clapham and could not see why he needed a local GP: he was unaware that GPs visit their patients if they are too unwell to get to the surgery. In this sense, I would say he was naive, he simply was unaware of how the system works. He was sensible enough to see that there was no way that I would trek across London to visit his sick bed.

the rather naive young man had been totally misled: this sentence brings up the other side of the coin. People can be naive through lack of experience, but this lack of experience can be taken advantage of by others. In this case, I think it is clear that the Department of Health are misleading people and taking advantage of their naivety. I will offer some concrete examples later.