3. If it is so stupid, why are they doing it?

05/06/2012

I have reflected for over 2 years about this. If the proposal to allow patients to register with any GP in England, regardless of where they live, is so stupid, how is it that all three main political parties back the proposal, the Department of Health backs the proposal, journalists do not question the mechanics behind it, and, in the ‘Consultation’ over three quarters of the members of the public who responded allegedly backed the proposal?

I would say there are a variety of reasons, but all in the end come down to a misunderstanding of the situation, of the facts. This misunderstanding is the result of:

Naivety

Ignorance (wilful and unwilful)

Stupidity (to different degrees, reaching at times the grotesque)

Misinformation (wilful and unwilful)

Deception

Duplicity

Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)


2. Why pursue this issue of practice boundaries?

05/06/2012

Why have I doggedly pursued this issue?

Because not only is it remarkably stupid and simply will not work, but it will also cause the current system, with all its complexity and problems, to malfunction.

Looking after patients at a distance creates all sorts of problems (it is inefficient, more resource consuming, at times unsafe), if people from outside an area register with a practice they will almost inevitably displace a local resident from registering with that practice, or at the very least take some of the resources away from the local population.

So it seems to me essential that we put a stop to this madness. And because in December 2010 nobody else seemed to giving this issue any attention, I decided I must so created this blog and started writing to MPs.

 


1. This really has to stop

05/06/2012

For over 2 years now most mornings I wake up earlier than I need to and my mind fixes on the issue of GP practice boundaries and, in one form or another, I think ‘How can they be so stupid?’ ‘They’ being the politicians, the Department of Health, journalists, think tanks, patient representatives. I don’t on the whole include members of the public, simple citizens in this. Because they are being fed stuff by the politicians, journalists, think tanks, and who could blame them for thinking it is reliable stuff?

Why am I doing this? Why am I writing this early on a Bank Holiday morning when I could be in bed sleeping, reading a book, gardening, or going to work to try to catch up on the massive backlog (which I will do later on as it happens)?

I came to medicine late, I was about 6 years older than my peers at medical school. I made a positive choice to become a general practitioner, because I welcomed the chance of working in a community, with families, over time. My wife and I started in our practice in Tower Hamlets 21 years ago. We, and our colleagues in the practice, try to provide a good service to our patients, and to create a healthy environment in which to work.

We, like all GPs, have a geographical practice boundary. To register with us you need to live within that geographical area, if you move outside that area you have to find another GP in whose practice area you live. It seems harsh, but there are a number of practical reasons for it. What I tell patients when they move is simply this: it is important that you be able to get to the surgery easily or for us to get to you easily if you are sick. (There are a raft of reasons why this, from a practical point of view, is necessary). Patients nearly always see why this is necessary.

We have quite a lot of experience of looking after patients who have moved out of the area and not told us. They have continued to use us as their GPs but it simply does not work properly, for a variety of reasons (in some cases it is unsafe, and can be fatal). So we are pretty firm with people on this score, but give them adequate time to find a new GP.

There is another aspect to this question. We work in Bow. We have a limit to how many people we can look after; if we exceed this capacity, the quality of the service we offer declines and the dynamics within the organisation become unhealthy. So we have an upper limit of the number of patients we will register. So if a patient moves away from Bow (to say Brixton), that patient’s place is then taken by another resident of Bow who wants to join us.

So when, in September 2009, I heard that Andy Burnham wanted to abolish GP practice boundaries and give people ‘real choice’, I thought: ‘How can that man be so stupid?’

Then there was the ‘Consultation’ in March 2010; the General Election which brought us the Coalition Government and Andrew Lansley; Andrew Lansley’s vision to bring everyone more choice, and his commitment to abolishing practice boundaries.

But the trouble for me was that I actually worked in the field that they were talking about, and I had daily reminders about the fact that general practice is a community based technology tied to geography, and that to severe its tie to geography simply did not make sense. It simply did not add up. There was a cognitive disconnect.

And so I woke up early asking the question, ‘How can they be so stupid?’ And having followed this issue over the past 2 years, I am still waking with this question, in fact it is seeming to me to be more and more stupid.

But it really has to stop.

 


‘Choose Your GP’ pilot: a confidence trick?

04/06/2012

4/6/12:

There are two main problems with the ‘Choose Your GP practice’ idea, proposed by all 3 main political parties, and welcomed by many well-meaning patients and patient groups who are frustrated in many ways by the current state of affairs. The first obstacle is that of capacity: most practices are currently working at full capacity. There simply is not significant spare capacity at that wonderful practice you have heard about 15 miles away. The second problem (and this covers a myriad of issues) is that looking after patients at a distance from the practice does not work: it is ok for people who are well, organised, and mobile, but not for people who are sick. This is how it is. Policy makers have to accept and work with these facts of nature.

In the press release on 30 December 2011 (why choose such a date?), we read:

“Busy commuters will benefit the most from the new pilot scheme, which 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.

The announcement means commuters in the pilot areas, who are often away from their local area during the working day, will find it easier to see their doctor where it suits them, and receive the same services as in their old practice.

The pilot, which will begin in April 2012 and last for one year, will also come as a relief to people who are moving home and wish to remain with their preferred practice, and families who would like a practice near to their children’s school.”

The press reported this, just reproducing, without any questioning or any irony, what the DOH press office gave them.

Where are we now? The launch had to be delayed by a month while the DOH ironed out some practicalities, and then the East London LMCs wrote to GPs advising them to boycott the pilot unless it was properly funded, then the recent LMC conference (if I am not mistaken) voted to reject the pilot. And then we have a robust report (see link below) commissioned by the Corporation of London and NHS London North East and the City analysing the primary care needs of the City of London with its resident population of 11,700 and one GP practice within its area, and approximately 360,000 working population who might want to avail themselves of Andrew Lansley’s offer. It is obvious that the current primary care infrastructure in the City of London is in no position to provide what Lansley and the DOH have offered. What were they thinking?

There was a Czech documentary in 2004 (Czech Dream) which perpetrated a hoax on the Czech public, with advertising for a hypermarket due to open shortly. But there was no hypermarket, just a life-size poster of a hypermarket held up by scaffolding. A crowd of several thousand gathered in a field for the ‘opening’, attracted by the promised sales, and ran across the field after the ribbon was cut.

In some ways, a similar dynamic is at work here. But I am not sure if Lansley or the DOH themselves are aware of the con. It is not reported in the press.

Report on City of London primary care needs

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30/1/15: The policy was in fact launched on 5/1/15, very quietly. It is a mess. Czech Dream, English Dream.


My email to ‘Choose Your GP’ pilot enthusiast

04/06/2012

The Department of Health’s press release for the Choose Your GP Pilot, contained this endorsement by a GP:

A Westminster GP Ruth O’Hare said:

“This initiative will mean that commuters working in the heart of London will in future have far greater flexibility around their choice of GP, enabling some to choose to see a GP closer to where they work.

“I welcome this exciting initiative which the Department of Health is resourcing as it offers patients greater access to NHS care at a time and place that is convenient to them.”

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I emailed this GP as follows:

From: Farrelly George (TOWER HAMLETS PCT)
Sent: 23 April 2012 07:38
To: O’Hare Ruth (WESTMINSTER PCT)
Subject: Yours views on ‘Choice of GP Practice’ pilot

Dear Ruth O’Hare,

I am a GP in Tower Hamlets. I will confess that I am sceptic with respect to this pilot, but I read in the DoH press release that you are an enthusiast. Seeing as how you are in essence giving a public endorsement for this policy, can I just ask for some very brief clarification (just ‘back-of-an-envelope’ thoughts)?

1. ‘I welcome this exciting initiative…’: please name 3 things that you find exciting about the policy.

2. Do you think there are any risks with the policy? If so, would you name three?

3. With respect to the broader policy of abolishing GP practice boundaries altogether, are you in favour of this proposal as well?

Many thanks.

Best wishes,

George

The Tredegar Practice 35 St Stephens Road London E3 5JD

www.onegpprotest.org

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


From: O’Hare Ruth (WESTMINSTER PCT)
Sent: 01 May 2012 09:37
To: Farrelly George (TOWER HAMLETS PCT)
Subject: RE: Yours views on ‘Choice of GP Practice’ pilot

Dear George,

I have discussed your email with local colleagues.

The response seems to be that this is a local issue and needs to be decided at CCG level and amongst local practices.

Best wishes

Ruth


From: Farrelly George (TOWER HAMLETS PCT)
Sent: 25 May 2012 12:34
To: O’Hare Ruth (WESTMINSTER PCT)
Subject: RE: Yours views on ‘Choice of GP Practice’ pilot

Dear Ruth,

I would have replied earlier but have been away.

Your endorsement on the DoH website, quoted in the press, did not say ‘This might work for some areas, but needs to be discussed at a local level’, but gave the impression that you thought this was a commendable policy.

I would ask again: are you able to give answers to the 3 questions I raised in my original email? Why do you, and indeed your local colleagues, think this is a good thing for general practice inWestminster?

You see, I believe this policy to be very flawed, very misguided. I have been unable to find anyone able to give a coherent and credible argument in its favour (Department of Health; Kings Fund; politicians; GP proponents). The magic word ‘choice’ is used, but nobody looks realistically at what this means in practical terms; proponents point to the government ‘consultation’ of 2010, allegedly showing that the public support having ‘choice’, but the consultation itself was in many ways a deception, painting a one-sided picture of what this ‘choice’ would involve, and omitting mention of any risks.

You are a GP in a position of authority; you have lent your good name to promoting this policy. Why?

Best wishes,

George

The Tredegar Practice 35 St Stephens Road London E3 5JD

www.onegpprotest.org

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


East London LMCs advise boycotting ‘Choose Your GP’ pilot

21/04/2012

Pulse has published an article on this, together with the letter.

My comment to the Pulse article:

Congratulations to the East London LMCs for taking this necessary step. Not only will the commuters using local GP practices be using local resources in terms of secondary care, community services, and prescribing costs, but do local practices really have the capacity to look after these additional patients without distracting them from their local registered populations?

PCT clusters throughout England are having to put in place contingency plans to look after patients who register at one of these pilot sites, but who then fall ill at home and need a GP. What is the cost of all of this? Where is this money coming from?

At all sorts of levels this is a crackpot policy. Either Lansley and the secret agents at the Department of Health are remarkably stupid, or, more likely, this policy is actually a smokescreen to de-regulate English general practice. Removing practice boundaries will open up general practice to an entirely different model which will be ‘liberating’ for organisations like Virgin Care, but will undermine British general practice.

They call this a pilot and they say that it will be ‘independently’ evaluated. I predict that as with other piloted policies, that plans to implement the nationwide roll-out will be made before the (sanitised?) evaluation is made public.

I believe it is possible to stop this policy, but this will require persistent clear-headed resistance to the impracticalities & inefficiencies that will inevitably be proposed. A light needs to be shone on this policy: why did none of the 3 political parties carry out a proper risk assessment of this policy? Why did the Department of Health avoid almost any mention of these risks in the so-call ‘Consultation’ two years ago?

It is really just a confidence trick, and the choice it promises is an illusion. The GP you’ve heard such good things about is actually working at full capacity already. The well-functioning practice you may have heard about works well with this population size, within this geographical area. Increase the list size, change the geography, and the system changes.

For more on this, see my blog www.onegpprotest.org


Email to MPs surname beginning with L: message/protest/warning from indignant GP in Tower Hamlets

12/02/2012

I am a hardworking GP in Tower Hamlets. My aim is to try to provide good quality primary care services to the local population of Bow.

I am indignant: you politicians and your colleagues at the Department of Health are designing policies which make my job harder, if not impossible. You dress it all up with words like ‘Choice’, ‘modernisation’, ‘reform’: but much of it is really just ‘sabotage’.

I am indignant: you are using a very stupid methodology. You avoid looking at risk; in fact, Andrew Lansley has gone so far as to keep risk secret. And you just seem to accept this. Is this intelligent?

I have been running a protest blog for the past year, and writing to MPs, one letter at a time. Now is the turn of the L’s. I know there is a convention that you don’t deal with issues raised by people who are not your constituents. (Do you read newspaper articles by people who are not your constituents?). Consider me a lobbyist then. I am lobbying on behalf of good quality English general practice. Am I paid to do this? No, it costs me. Do I stand to gain financially? I don’t think so.

I am doing this because I am indignant. This email, my blog, my activity on Twitter, is my protest, my tent pitched in the square.

My protest, my focus has been primarily on the issue of GP practice boundaries.

All 3 main political parties are in favour of the policy of abolishing GP practice boundaries, and allowing people to choose their GP practice without the constraints of geography, anywhere inEngland. When I first heard this proposal over 2 years ago, I could not believe that anyone would propose such a thing, so mad did it seem.

I will be brief, and if you want additional information, go to my blog. See links below.

1. You would think that anyone drawing up a proposal to change the structure of general practice inEnglandwould do some sort of robust assessment (including risks, unintended consequences, etc.) before launching the policy in public. This is basic, I think you would agree. Yet for this policy, there is no evidence that the Conservatives, Labour, or the Liberal Democrats ever did a risk assessment. I emailed Andrew Lansley in March 2010 and with some difficulty extracted the evidence that they had not carried out any risk assessment or feasibility study. New Labour and Andy Burnham’s evidence lies in the Department of Health’s documentation surrounding the so-called ‘Consultation’ Choosing Your GP Practice, launched in March 2010. This documentation lacks any serious examination of risks and unintended consequences. The documentation is essentially a PR exercise designed to elicit a ‘Yes’ to the questionnaire, which politicians have since used as ‘evidence’ that the people of England want to be able to choose a GP practice anywhere in England. Indeed, on more than one occasion, Andy Burnham has said, ‘I can see no reason why people cannot register with the GP of their choice.’ Not even one reason: clearly, Andy Burnham, despite being Secretary of State for Health, had not done a risk assessment. And he continues to say this sort of thing, as recently as December 2012. I have asked the Liberal Democrats (more than once) for any evidence that they carried out a risk assessment; silence.

This sloppiness, recklessness, arrogance: it makes me indignant, very indignant.

2. Your policy promises to give the people of England greater choice, ‘real choice’ as Andy Burnham has said. This choice is really an illusion. What you must understand is that the vast majority of GP practices are currently working at full capacity. They do not have spare capacity to absorb significant additional numbers of patients. Your idea is that the popular, well-performing practices that offer a good service will attract patients from the poorly-performing practices. This will simply not work, not to any significant degree.

Indeed, there is a risk that local people will not be able to register with a local practice because people outside the practice area have taken up part of the limited capacity. So far from doctors competing with each other, we will have patients competing with each other for places in a desirable practice.

And if you force practices to register all comers (as is currently the case with the 2004 GP contract), then the standards will fall.

Politicians and the Department of Health simply do not seem to understand the reality of capacity, and its relation to quality. This is very basic. It is shocking that an organisation that is supposed to organise a National Health Service should be so stupid.

Put another way, it is essentially a zero sum game. For some there may be some scope for expansion, but this will have its limits. Perhaps you can understand this if you think of the game of musical chairs. There are a limited number of chairs, more or less enough for the English population. Your modelling appears to assume the chairs are unlimited.

3. Then there is the reality of how general practice works: it is a local technology. The service works for a local community, and has links and networks to local services. We have worked in our community for 21 years. When people move away, they try to remain registered with us; our experience over the years is that this does not work, and is at times unsafe. I give examples of this on the blog.

To actually restructure things so as to remove the locality-base means to destabilise how the system works: it leads the system to malfunction.

You think you are doing something good when in fact you will cause a system under a fair amount of strain to malfunction: you are unwittingly sabotaging primary care. And you call this ‘modernisation’.

This too makes me indignant.

4. Let me return to capacity and quality, which is another focus of my protest on the blog. The current rules on patient registration is that we should register anyone in our practice area who wishes to register with us (=patient choice). But we found that this would destroy us; so we decided, unilaterally, to refuse to do this. We keep our list size at about 3,520; as people leave the area and the list, we register new patients. We have been quite open with the PCT and the LMC. The reasons are documented on the blog. I wrote to the Department of Health about this, and met with the then GP ‘tsar’. He agreed with me that this was not a sustainable situation, and said this was not a national policy but a local mistaken application of a national policy. I did not think this was the case. I asked who was responsible for this policy. He did not know. He did not offer to find out.

The recently published guidance to PCTs on the implementation of the pilot for commuter patients in 3 English cities (Tower Hamlets is included in the pilot) reiterates this directive: what we are currently doing is prohibited. We would have to either have to take all comers or shut the list to everyone (with the permission of the PCT). The guidance says that otherwise patients get confused. In our experience, patients understand this entirely and are not confused by it.

This is a very stupid policy and we will continue to adopt a stance of civil disobedience, and protest against it.

This too makes me indignant.

5. So if abolishing practice boundaries is so stupid a policy, why are they doing it?

There is a hidden agenda. What I believe this is really about is the deregulation of English general practice, the marketisation of general practice. Whilst the Department of Health goes on and on about patient choice, the true incentive is this: by eliminating practice boundaries, it will allow for profit organisations to set up primary care centres which can register people regardless of where they live. These centres will have no commitment to a community, to a locality. They will be based in city centres and their patients will be the healthy and mobile. If these patients get sick and are unwell at home, the centres will not have to look after them because they will not be local, they will be at home. Someone else will have to provide care for them where they live. (See the Department of Health guidance document, section 6).

Abolishing practice boundaries will ‘liberate’ the NHS for these entrepreneurial groups. These will essentially be glorified walk in centres catering for the healthy.

This too makes me indignant.

6. The proposed policy to abolish GP practice boundaries is a relatively small part of the Health Bill, and not on most people’s radar. But for general practice it is a very important issue.

The opposition to the Health Bill is growing inexorably. Even Tories are worried about the fall out. Andrew Lansley and David Cameron say they are determined to soldier on.

Let me give you a warning from the front line. Much of this Bill is built on PR: Choice, Modernisation, Reform of the NHS. Whenever Andrew Lansley or David Cameron or Simon Burns are questioned about an aspect of the Bill, these words will be central in their answers.

But what lies underneath all this? My wife is a member of the Tower Hamlets CCG. She is committed to trying to commission good services for the people of Tower Hamlets, but she thinks the structure that Andrew Lansley has designed makes the project unworkable.

I have studied the practice boundary issue carefully. It is a scam. My suspicion is that other aspects of the Bill are also scams.

If you push this Bill through, which seems to be the likely outcome as I write, things will unravel. They will unravel because built into their design are flaws. If this Bill was a building, it would not stand up, it would collapse. If it was a bridge, the bridge would collapse. So things will begin to malfunction, and it will be clear to all of us that they are malfunctioning because of design faults which are your responsibility.

At that point, the penny will drop. People will realise that they have been had, that all the rhetoric was just PR, emperor’s new clothes. And there will be anger; and this anger will be directed, rightly, at you. The warning signs are there: you can choose to pay heed, or you can plough on.

Reflect on this statement by Richard Feynman, the physicist, which I have adopted as the motto for my blog: ‘For a successful technology reality must take precedence over public relations, for nature cannot be fooled.’

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Links:

1. My email exchange with Andrew Lansley

2. The problem of patient registration policy, in a nutshell

3. Your Choice of GP: the problem in a nutshell

4. The problem of caring for patients at a distance; examples

5. Email exchange with an MP attracted by the idea of being able to choose a GP at a distance

6. Email exchanged with The King’s Fund on GP practice boundaries

7. Department of Health Choice of GP Practice – Guidance for PCTs Jan 2012

8. Department of Health’s ‘Consultation’ PR exercise Your GP Your Choice Your Say


My initial comment on Government pilots on boundary-free general practice: is it a fraud?

08/01/2012

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.

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This story will develop in the coming months, as the practicalities begin to bite.


Thoughts on the GPC-DoH Agreement on GP Practice Boundary Issue

13/11/2011

News reached us just under 2 weeks ago the GPC and Department of Health had reached an agreement about the issue of practice boundaries. There are two provisions: 1. practices will be encouraged to reach an agreement with their PCTs about an ‘outer’ practice boundary which will allow patients to remain registered should they move outside the ‘inner’ practice boundary, ‘where clinically appropriate’. 2. There will be two or three city pilots for commuter patients to register with a participating practice close to their work, and an independent evaluation will be carried out.

I have campaigned on this issue, having seen the orignal proposed policy (patients in England being able to register with the GP practice of their choice, ‘anywhere in England’) as quite mad and unworkable. I am pleased with this outcome, and the GPC is to be commended for having negoiated this. As should the GP body that resisted the proposal.

This current arrangement implicitly recognises that general practice is a local and community-based technology, which the previous proposal (which all 3 major parties subscribed to) ignored entirely. Even the commuters will need to register with a practice not far from their work.

Of course, there are significant practicalities which will need to be addressed: who pays for the costs of the commuters? How is this money transferred? How does this fit in with Clinical Commissioning  Groups and commissioning? Certain areas, such as the Isle of Dogs in Tower Hamlets which hosts Canary Wharf and a commuter population of about 100,00, will be affected very significantly. And then, what happens when the commuter is ill at home, how does he or she access local help, especially if the illness needs more than one GP encounter?

It is absolutely vital that the ‘independent evaluation organised by the Department [of Health]’ be truly independent and honest and rigorous (that is, not on the model of the so-called ‘consultation’ on this issue carried out by the DoH in March-July 2010 which was PR exercise which misled the respondents and Parliament).

It must be said that the inner and outer boundary model is something that some practices have had in place for many years already. Under the agreed provision, practices will have the option of having an ‘outer boundary’ and clearly they will have to choose a boundary that allows them to deliver a functioning service. That is well and good.

It is very important that the politicians and DoH do not attempt to resurrect this mad idea in the future, and that we make it clear to everyone that UK general practice is at its core a locally based technology which simply does not work on the same model as McDonald’s and mobile telephones. It may be possible to make exceptions in certain circumstances (such as the commuter), but this is an exception rather than the thin edge of the wedge.

A large wooden stake needs to be driven firmly into the heart of this vampire. That is why I will continue to write to MPs and continue to write about this issue because I have not covered all the ground yet.


The policy to abolish GP boundaries: a scandal in search of an audience

18/09/2011

These notes are to accompany the ‘opinion piece’  I was asked to write for Pulse, the GP weekly, on the matter of the Government’s proposal, contained in the Health and Social Care Bill, to abolish GP practice boundaries. There are links below to back up my assertions.

In essence the issues are as follows:

The proponents of the policy argue that:

  • GP practice boundaries are anachronistic and no longer serve any purpose
  • The are ‘old fashioned’, and limit patient choice
  • That abolishing practice boundaries will give patients ‘real’ choice and drive standards up
  • They point to the results of the New Labour/Department of Health ‘consultation’ on GP boundaries March-July 2010; over three quarters of the public who replied to the ‘consultation’ questionnaire were in favour of the policy to allow patients to register with the GP practice of their choice, ‘anywhere in England’

To the man or woman in the street, this sounds like a good idea, what’s not to love about it? Having choice is a lot better than limited choice.

But people who actually work within primary care will know from first hand experience that this proposal simply does not add up, that looking after patients who live at a distance creates all sorts of problems.

  •  Good quality British general practice is a complex technology. It serves a local population, and the vast majority of the transactions are local ones.
  • Distance from the practice is a barrier to care: patients attend less
    frequently, delay seeing us (sometimes inappropriately), save things up and bring more items to the consultation (which cannot be dealt with effectively), are more likely to not attend booked appointments, are less likely to attend for appointments that we initiate (chronic disease monitoring).
  • Patients who are not local cannot integrate with local essential services: the community mental health team, local health promotion initiatives, physiotherapy, chiropody, social services, local community pharmacists. We in primary care build up relationships with all these services, and cannot duplicate this easily with a myriad of similar services in different parts of the country.
  • Sometimes it is unsafe. Patients need a visit because they are too ill to travel (made worse by the distance), and they are too distant to visit without putting an unsafe burden on the practice which will impact on the service that we are trying to offer to the local population.
  • Looking after people introduces a number of inefficiencies which are a drain on practice time which is an important resource. And this at a time when we are being asked to make efficiency savings.
  • If we register patients who are not local, then this may mean not registering patients who are local (if there are capacity issues). This introduces the risk that over time local practices will no longer be serving a local community but a mixture of local and non-local patients.

I assert in my opinion piece that the Government and DoH are offering something they cannot deliver. They are either offering this out of ignorance (which is quite shocking) or because they have a hidden agenda and this offer of ‘choice’ is therefore an act of deception, an act of corruption (which is even more shocking).

What is the evidence?

The politicians and DoH are asking us to do something which most of us GPs and practice staff know simply does not work. They are asking us to adopt a policy which will make the system malfunction. In their communications the gloss over entirely any problems, any practical issues, and just repeat, like a mantra: ‘we must offer patients choice’, and ‘over three quarters of the public are asking us for this’. That is in essence the argument for. They say nothing about the ‘consequences of this choice’.

I sought evidence from Andrew Lansley in March 2010 (when he was in opposition, and pushing this policy) that he understood the complexity of quality British general practice, and that he had carried out a feasibility study or risk assessment. It took some perseverance on my part, but I eventually got evidence that he had not carried out any sort of risk assessment (see below).

New Labour’s record is contained in the so-called ‘consultation’. This is really a blatant public relations exercise which sells something it cannot deliver; the questionnaire that members of the public and health professionals answered was skewed in a way to make it more likely that a member of the public would answer in a given way (to vote in favour; in fact, it is difficult to see why members of the public did not all vote in favour). So the consultation process was an exercise whose aim was two-fold: first, to make it appear that New Labour were taking this seriously (so outflanking the conservatives), and offering something to the public which might garner them votes, and then, second, coming up with ‘evidence’ that the public are in favour of this policy and using this as an argument to implement the policy. The consultation documentation is misleading, a deception. The public were deceived, and parliament was deceived. And the results of this deception are being used by ministers and the DoH to implement a foolish policy.

But why would they want to do it?

At present there are a handful of English GP practices owned and run by private, for profit companies. But they have to operate at a local level. This is quite restrictive. By abolishing GP practice boundaries, the whole framework is opened up for these companies. They can set up health centres which will be able to register patients from anywhere. They will be glorified walk in centres, for the mobile well. They’ll leave home visits to someone else, and those who are really ill will find quickly that they need a local doctor. It is highly likely that for many years the likes of Kaiser Permanente and United Health and McKinsey have been whispering in the ears of ministers and DoH policy makers, and this is why there is a push to abolishing GP practice boundaries.

What can we as GPs do?

I think it is essential to bring this issue into the public arena. It is quite simple, really. Most of us (there will be a few mavericks, ‘doctor-preneurs’, who will of course be in favour because that is where the money lies) will feel that this is a terrible policy which will undermine good quality general practice and be a threat to local communities. In the interest of maintaining good, safe standards, we should be quite vocal about this, draw it to our patients’ attention. And the GPC MUST RESIST this very very robustly.

We can refuse to do it: This would be a form of strike, but a strike which actually would not harm the service at all, in fact would be protective of the service. You see, we have a very strong argument on our side; the Government have a house of cards which will unravel once our patients are aware of the facts (which are not terribly complex), and the media begins to take an interest. Indeed, I think the Government will want to avoid a light being shone on this issue because it is so corrupt.

 That is why I say that this issue is a scandal in search of an audience.

[Your views are welcome, comment below]

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Links to documentation:

1. My email exchange with ‘Andrew Lansley’. This is a shocker.

I have emailed the Lib Dem MPs asking them the same question I asked Lansley. So far, no answer. I will of course persevere.

2. Patient leaflet for the Government ‘consultation’ on Choosing Your GP, March 2010.

If you read this leaflet, why refuse the offer?

3. Full ‘consultation’ document (includes the questionnaire).

I would be interested in the views of professionals who design questionnaires. What do you think of the design of this questionnaire?

4. Royal College of General Practitioner’s response to the ‘consultation’

5. Concrete examples  from our everyday work.

6. Miscellaneous:

My email exchange with The King’s Fund

My email to the Patient’s Association

My email to an MP

Is this the future? Virgin Assura Medical

Strategy of US for profit companies: read this

Trust in professionals poll 2009