My email to Stephen Dorrell, Chairman of Health Select Committee, on GP practice boundaries

20/10/2013

Dear Stephen Dorrell,

I sent a submission to the Health Select Committee in May 2013 raising concerns about the Government proposal to abolish GP practice boundaries (1).

A concluding paragraph read as follows:

I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent.

I sent an email to Jeremy Hunt on 8/9/13 raising my concerns (copied to you) (2); in response I received an evasive and irrelevant reply from the Department of Health (3); I sent a second email to Jeremy Hunt a week ago (again, copied to you) (4).

You were contacted by Pulse following my submission in May (5), and the article suggested that the Health Select Committee were going to investigate the policy. Has it done so? If yes, why was I not called to elaborate on, and to substantiate, my charges? If you have not investigated this matter, do you intend to and when? If you do not intend to examine it, why not?

I am aware that there is a glaring conflict of interest here, both for you personally and for your entire committee. Were you to investigate this policy, it would be very difficult to avoid coming to the conclusion that at best those involved in the planning and promotion of the policy were naive and ignorant and grotesquely incompetent (in short, a ‘blunder’); but, worst still, you might be unable to avoid concluding (as I have) that there has been a wilful misleading of the public and of parliament, that it is not just a blunder but actually a scam, a fraud. This would be embarrassing for your party as this, remarkably, appears to be a flagship policy for the Government (6),  and embarrassing for the Labour Party (one of the prime promoters of this policy was Andy Burnham when he was Secretary of State for Health; he is now the shadow minister for health and his credibility would be severely damaged if a light were shone on his involvement). So I expect you will do all you can to avoid looking at this honestly and fully. And that in itself will raise further questions.

If your committee is unable to scrutinise this policy thoroughly, then who should?

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

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16/11/13: Yesterday it was announced that GP practice boundaries would be abolished as part of the new GP Contract. I have not heard from Stephen Dorrell or any member of the Health Select Committee. 

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26/7/14: I never received a reply to this email which was copied to all members of the Health Select Committee

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1. My Submission to the Health Select Committee

2. My email to Jeremy Hunt, 8/9/13

3. Response from the Department of Health

4. Second email to Jeremy Hunt

5. Pulse article 10/5/13

6. Coalition Government claim that the ‘pilot’ is evidence that they have improved the NHS


My second email to Jeremy Hunt on the fraudulent GP practice boundary policy

13/10/2013

Dear Jeremy Hunt,

I sent you an email on 8/9/13 raising concerns about a Government policy. I received a ‘reply’ from a Department of Health official (for my original email and the reply, see below). A first year GCSE student would have no trouble seeing that this is no reply at all: it is a bland, seemingly innocuous, description of the ‘pilot’ into general practice without boundaries. It does not address my concerns at all (1).

I ended my first email with a quote from my submission of May 2013 to the Health Select Committee:

I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent (2).

The DH reply only reinforces my hypothesis that this policy is a scam, a deception, a confidence trick.

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I have been following the development of this policy for over 3 years now. I have not been able to find an example, a metaphor, which would help people to understand the sheer stupidity of this policy. And then last week I came across a news item that I think is of help. Briefly, it is this: a British entrepreneur was convicted in April 2013 for fraud; his fraud was selling bogus bomb detectors to the Iraqi government. He made a lot of money; the bomb detectors did not work; innocent people were blown up; these bogus devices are apparently still being used in Iraq to ‘protect’ the citizens.(3)

I believe this story, this parable, offers a structure that helps make sense of the policy which you, as Secretary of State for Health, have inherited. There is a product, a technology, which is said to perform a function (detect bombs, avoid disasters); the technology is marketed (presumably there was promotional material; presumably it came in a box with reassuring messages on the box); the buyer is persuaded to pay for the technology; the technology is put to use; the technology does not work.

(This sad, shocking story raises a number of questions which I will not address here; but one question is this: why did they not test the device? Presumably the entrepreneur and his firm told the buyers that it had been tested, perhaps they said the device was already being used in other war zones).

Now let us come back to the policy of abolishing GP practice boundaries. British general practice is a complex technology which by its very nature is local, geographically based. Our experience has been that when people move away from the practice area it is no longer possible to look after them properly, especially if they are unwell. So when I heard politicians saying that boundaries were old fashioned and limited choice I was bewildered. I heard Andy Burnham say that this policy would transform the NHS from ‘good; to ‘great’, that poorer patients would be able to take advantage of services that were offered to richer patients; I heard them say that this policy would promote competition and that this would drive up quality. Most of what I heard was very foolish, it did not make any sense, it was nonsensical, it would simply not work, it would not deliver what they were promising, it would actually undermine our work.

Now just in case you think I am some sort of eccentric, some nutty GP who has an absurd bee in his bonnet, ask yourself this: why did the former GPC Chairman Laurence Buckman describe this policy as ‘bonkers’? And why did the annual LMC conference in 2011 vote unanimously (something unheard of) a motion urging the GPC to resist this policy ‘staunchly’?

So, Mr Hunt, what I am saying is this: the technology your Government are proposing simply does not work. Your predecessors, the various promoters of this policy (politicians, the Department of Health, aided by compliant journalists and think tanks) have presented the public with an attractive box, with catchy packaging, which promises a great technology. But the device in the box is bogus, it does not actually work. Just like the bogus bomb detector. They have done no honest testing of the technology in the box. You pretend to test it, as with the sham pilot and the questionable ‘evaluation’ (4).

You see, Mr Hunt, I understand the technology. This is my area of expertise. And I am saying that the technology that your Government is promoting is very faulty and it will not deliver what you are promising. Either you are all remarkably stupid or you are perpetrating a fraud.

The entrepreneur who committed the bogus bomb detector fraud has been arrested, charged, convicted, and sent to prison for his fraud (but not, apparently, for the harm he has caused to a large number of people).

If I am correct in my hypothesis that the Department of Health and ministers are engaged in a deception, a fraud, then should they be charged? And if not, why not?

So what do I propose? I propose that the Health Select Committee open the box and scrutinise the contents carefully, honestly, dispassionately. But are they capable of doing this? I am sceptical. When the Chairman of the Health Select Committee, Stephen Dorrell, was phoned by a Pulse journalist following my submission in May, he said he was broadly in favour of the policy: ‘Where there is choice different people will have different ways of solving the problem and provided that they are all consistent with the commitment to universal delivery of high quality care then I think that the [option] which allows people to consider different ways of solving shared problems is in the interests of all patients.’ (5) This is typical of the rhetoric that is used when discussing this issue; the word ‘choice’ is inevitably used, ‘high quality’, ‘interests of all patients’. But it means nothing. It is all packaging, spin. It does not address the technical problems at all. Mr Dorrell needs to open the box and look at the technology inside the box, not to approvingly describe the packaging.

There is of course another very important question here that I feel, as a professional and as a citizen, needs to be addressed. What is wrong with the system that we have come to this? How is it that policy has been allowed to develop in this way? This is not just a ‘blunder’.

So perhaps it would be better for an independent body to look at what is in the box.

I would also propose that journalists wake up. Look inside the box, ask if it really performs the functions that the promotional material claims (but, for heavens sake, do not use the DH as your source of information). Ask questions; educate yourselves, try to understand the ecology of UK general practice. If any of you are interested, I would be happy to take you through the issues in plain English. Who knows, there might be an Orwell Prize at the end of it all.

Mr Hunt, you have a real problem here. If you implement this technology the problems will become apparent, the design faults will be exposed. You will no longer be able to fall back on the attractive box and the glossy promotional material. You will not be able to say you were not warned.

In the end, Mr Hunt, you cannot get away from this reality, eloquently stated by Richard Feynman: ‘For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.’

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

Notes:

1. The reply from the DH: for reply & my comment; for my first email to Jeremy Hunt
2. For my Submission to the Health Select Committee
3. Bogus bomb detector fraud
4. Questionable ‘evaluation’ of pilot
5. Pulse article ‘MPs to investigate GP practice boundaries’; I do not think they have actually investigated this issue. Nobody has called me, I have not seen it mentioned in the announcements from the Health Select Committee.


Department of Health response to my email to Jeremy Hunt: the smell of rotting fish

21/09/2013

Yesterday I received the following email from the Department of Health. It alleges to be a reply to my email of 8/9/13 to Jeremy Hunt. It does not address any of the concerns I raised in that email. It is quite random, though it does contain some worrying messages, no doubt unintentionally.

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Dear Dr Farrelly,

Thank you for your correspondence of 8 September about the pilot scheme to remove GP boundaries in six primary care trust (PCT) areas.  I have been asked to reply.

The purpose of the piloting arrangements was to trial the scheme with a limited number of practices in a limited number of PCT areas, the aim being to test whether these arrangements still provided patients with the best possible primary medical services.

Where a patient chose to register with a GP away from the area in which they lived, any urgent or immediate care was be the responsibility of the PCT for the area where the patient lived.  When registering, it was made clear to patients that they may be contacted to discuss their experience of being registered with a GP practice under these arrangements for the purposes of evaluating the arrangements.  Participating practices and PCTs were also interviewed.  An evaluation report has now been received by NHS England and is receiving consideration.  Following that consideration, a decision will be taken on whether to extend the arrangements across England.

I hope this reply is helpful.

Yours sincerely,

Patrick Driscoll
Ministerial Correspondence and Public Enquiries
Department of Health

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I will be sending another email to Jeremy Hunt. In the meantime, it is worth noting that the DH official says that an evaluation has been carried out and the results sent to NHS England and is receiving consideration. Now this is surprising because the DH announced a year ago that the pilot would be extended by six months due to the chaotic first six months of the pilot. This would have meant that the pilot would have ended now, in September 2013. At this point, now in September, the evaluation could have been carried out. Instead we are told it has already been carried out. I smell the stink of rotting fish.

Another worrying message is this: the evaluation has looked at the experience of the (very few) patients who have participated in the pilot. Now of course they will say it suited them down to the ground. Practices will have been interviewed about their experience. I wonder what questions they were asked. PCTs have been interviewed: now this I very seriously doubt since PCTs disbanded in April 2013. And did they interview Tower Hamlets PCT and City & Hackney PCT, and ask them why they boycotted the pilot?

Worst of all is the fact that the evaluation is a sham as it does not evaluate the policy itself; the methodology itself is rigged to give them the outcome they wish, and to hide the very real problems that beset this brain damaged policy.

Shame on you Department of Health, shame on you Coalition Government.


My warning to Jeremy Hunt on policy to abolish GP boundaries: is it fraudulent?

07/09/2013

Dear Jeremy Hunt,

I am a GP in Tower Hamlets. I am writing to draw your attention to a policy which your government supports (as did the previous Labour government): the proposal to abolish GP geographical boundaries and to allow (encourage) patients to join practices at a variable distance from their homes. This patient ‘choice’ appears on the surface to be a welcome development. But as someone who has worked as a GP for over 25 years, it simply does not work: looking after patients at a distance from the practice introduces barriers to care; it is inefficient; it drains resources; it is at times unsafe. Moreover, it undermines the service to local residents. And this is just the tip of a very large iceberg.

Andy Burnham, when he was Secretary of State for Health, claimed that abolishing GP practice boundaries would transform the NHS from ‘good’ to ‘great’. To me this is a remarkably stupid statement.

And your government, in its Mid-Term Interim Review The Coalition: together in the national interest, refers to a pilot allegedly set up to test this policy as one of three examples of how the Coalition has improved the NHS:

“We have improved the NHS by: ….-allowing patients in six trial primary care trusts to register or receive a consultation with a GP practice of their choice.”

This sentence is wrong on a number of counts. The pilot in question allows patients in England to register with a  participating GP practice in one of six PCTs: the number of practices participating in this pilot is small (42 practices out of a possible 345 practices, or 12%). And the number of PCTs is in fact four because two of the PCT areas have boycotted the pilot due to concerns that it would be a drain on resources for local residents.

Perhaps as Secretary of State for Health you should find out why 2 PCT areas have boycotted the pilot, and why such a small number of GPs have agreed to take part in the pilot.

I have written to the Health Select Committee about this and you can access my submission here. I have published articles about this in Pulse (access here) and in a separate blog.

I have been following this issue for four years now. At first I thought the politicians and Department of Health were just remarkably stupid; but then I realised that the more likely explanation is that behind this policy was actually a financial one, profit for someone. And indeed it is organisations like Virgin Care who stand to gain from this policy, not patients, not primary care services.

And this is troubling because people say that you are a friend of these organisations. Is this true?

I will close with a quote from my submission to the Health Select Committee:

I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent.

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London
E3 5JD


Warning to Health Select Committee on a policy damaging to general practice, from a whistleblower

06/05/2013

I wrote to you several months ago to check if you would be the appropriate body to deal with my concerns about a Government health policy. Two of your members kindly responded and said that it did seem appropriate for your committee. So I am now writing to ask you to look into the Government proposal to abolish GP practice boundaries.

Summary:

The Government and Department of Health wish to abolish GP practice boundaries, saying that it will increase patient choice, drive up quality, and remove anachronistic constraints. From my perspective as a GP with 25 years’ experience of trying to provide good quality general practice to a local community, this policy may sound attractive on the surface, but in reality will simply not work and will cause general practice to malfunction; in some cases it will be unsafe. The Government and Department of Health are either remarkably stupid, or they have a hidden agenda and are engaged in an elaborate deception.

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1. Who am I and why am I campaigning against this policy? I am a GP in Tower Hamlets. I have worked in our practice for 22 years. I was the medical director of the Tower Hamlets out of hours GP co-operative from 1997 to 2004.

I feel very fortunate and privileged to be working as a GP. Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

As GPs we serve a local community. Over the years, in our practice, we have had lots of experience of looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney. We have found that these patients tend to delay being seen; that it is more difficult and time-consuming to manage their illnesses; sometimes they are too ill to travel to see us, and we are unable to visit them. At times it is unsafe. (Examples provided in links, see below).

So we are firm with patients about registering with a local GP.

When in 2009 politicians began to say that they wished to abolish practice boundaries, I was bewildered.

2. There are two main reasons why this proposal makes no sense: one, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; two, because GPs are all currently working at full capacity. The ‘good’ practices are already ‘full’ and cannot accommodate a significant increase in demand. There is a risk that ‘outliers’ will take the place of local residents, or impact negatively on the services of local residents.

So there is a very serious design fault at the heart of this policy. For the past 2 years I have been blogging, and writing to MPs, to Ministers, to journalists to draw attention to the problems inherent in this policy.

Last Autumn I wrote 6 articles for Pulse on this issue.

These articles are also published on a separate blog.

3. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But I now think that the evidence (evidence that is in the public domain) points towards a more disturbing process at work: that there is a hidden agenda behind this policy. My hypothesis is that the real aim here is to de-regulate general practice. At present, because it is geographically defined, it limits the type of business model that can be used to gain access to general practice. By removing the geographical element in primary care, you change significantly the business models and frameworks that can be applied.

But in order to abolish GP practice geographical boundaries, it has been necessary to create a pretext, or a series of pretexts. A narrative has been created and it has these elements: most people are happy with their GP; but some are not, and they should be able to have choice; GP practice boundaries constrain choice, they are old fashioned, anachronistic; there are a number of reasons why patients might want choice: to have a GP close to work, to register with a GP near their child’s school, to remain registered with their trusted GP should they move away; there might be a GP skilled in a disease in a practice outside their area; the only thing that is needed to make it all work is to sort out how visits will be done should the patient need one.

What this narrative leaves out are the two areas mentioned in (2) above: the systemic problems of patients living at a distance from their GP, and the problem of capacity. It also fails to mention the problems inherent in providing visits for people registered at a distance from their practice (see below).

4. Andy Burnham, then Secretary of State for Health, went to The King’s Fund in September 2009; in his speech he announced his Government’s intention to abolish GP boundaries within a year. He said this move would make a ‘good’ NHS ‘great’ (at least this is what the press reported; I have asked the DH to show me the press release for this occasion; thus far they have been unable to produce this). But what he said about this in his speech really amounted to nothing, it was meaningless to anyone who understands how general practice works (and does not work).

5. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice, launched in March 2010. If you look at this ‘consultation’ with a critical eye it is clear that it steered the readers towards responding in certain ways to the questionnaire. It used the narrative outlined in (3).

When it published the results of the consultation, the DH claimed it showed that the public backed the idea of choosing your GP practice and doing away with practice boundaries. Of course it showed that, it was designed to show that. Had they been honest about the reality of general practice, the respondents would have said: given what you have told us, why are you even proposing this policy?

6. The DH agreed with the GPC to hold a pilot around this policy. The pilot is in progress. The present Government went so far as to say, in their Mid-Term Review, that this pilot was evidence that the Government had improved the NHS. “We have improved the NHS by …..—allowing patients in six trial primary care trusts to register with a GP practice of their choice.” What the report omitted to say was that GPs in two of the six PCT areas opted to boycott the pilot because of concerns of the impact on resources of the local health economy (one of the many problems inherent in this policy). What they also failed to say was that of a possible 345 practices in the pilot areas, only 42 practices had opted into the pilot, and that as of the beginning of the 2013, only 514 patients had registered with a practice under the scheme.

This ‘pilot’ in no true way tests the policy. The Government and DH say that there will be an independent evaluation of the pilot. Given their behaviour so far, my concern is that the ‘evaluation’ will somehow avoid scrutinising the policy, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

7. The problem of visiting. People on all sides of the debate have acknowledged that the issue of visits would need to be addressed. But what most people have failed to grasp is the magnitude and breadth of this issue. At present, all patients are visited by their own GPs within working hours (8am to 6pm [or is it 6:30?]), Monday to Friday. And if the call is outside these hours, then there is a local arrangement for how these visits are covered. There have been problems with out of hours provision, with some high profile cases where patients have died due to not being assessed properly.

If this policy is enacted, then every area in England will require a structure to provide care for those who live at a distance from their registered GP. This provision will have to cover not only the out of hours time slots, but will of necessity be 24 hours a day, 7 days a week.

It is also important to understand that when a patient is seen out of hours, the notes from the encounter are sent to the registered GP. Almost always the notes contain a message that says something like this: ‘If not improving, for review by own GP.’ The trouble with the boundary free model is that there will be no local GP to manage the patient while unwell during working hours and at home. The out of hours service does not provide continuity of care, and does not arrange further investigation and referral where this is warranted.

8. I think there is a case for finding a way to make good quality primary care accessible to people who work long hours at some distance from their homes. But the people designing a solution would have to adopt a sound methodology which would include honesty, common sense, and truly taking into account the ecology and practicalities of general practice.

9. I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent.

10. I am writing as what some might call a ‘whistleblower’. That a busy GP should have to spend all this time in trying to get this message through to the politicians seems to me absurd. I am writing in the hope that you will listen and scrutinise this policy. But I am aware that there are many reasons why you as a committee might wish avoid this.

I am also writing so at least at a future date, when the inevitable problems surface, that you will not be able to say ‘Nobody warned us.’

 

Yours sincerely,

George Farrelly

 

The Tredegar Practice 35 St Stephens Road London E3 5JD

 

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Backing documentation

(Numbering corresponds to the paragraph numbering above)

2.. Looking after patients at a distance from the practice does not work and it at times dangerous:

Blog posts by me.

3. a. The narrative: the mainstream press has so far largely just reproduced what the Department of Health Mediacentre have told them in the form of press releases. There have been three main press releases, and corresponding articles in various media. Analysis of these articles shows that mainstream journalists for the most part do not understand how general practice works, and that they have uncritically taken the DH formulations and promises as fact, when in fact they often do not make sense.

 See my post.

In time, the mainstream press may well wake up and look into this issue.

b. The problem of capacity:

In our practice we have struggled with this. Because we are popular, people have wanted to register with us. This has driven us to a list size beyond our capacity which has a negative impact on the quality of the service we provide for our patients, and we have a workload which is unsustainable. The only way we have had to cope with this is to shrink our practice area further a few months ago. So there is no way we could cope with an influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised), we are drowning as it is.

I came across an example which illustrates this problem recently. There is a practice in Kentish Town with a long established reputation; just the sort of practice that people for several miles around might want to join (if I did not know better, I would consider joining as they are less than 2 miles from where I live). If you go to their practice website you will see the issues they are wrestling with as raised by their patient representation group.

They are having trouble providing access to their currently registered patients, all of whom reside within their practice boundary.

Another example which illustrates this in a farcical way. The DH chose City and Hackney as one of their pilot sites. The City is served by one practice, which has a list size of under 10,000. As it happens, the City of London Corporation and NHS Northeast London had commissioned a study into the practicalities of providing primary care services to the commuter population of the City. The conclusion was that something like 120,000 of the 360,000 commuters were likely to want to register with a GP practice in the City, which would require 50 more GPs, and additional practice nurses and infrastructure. So there was really no way that the sole City practice was going to be able to cater to commuters interested in taking part in the pilot.

See my article.

4. On Burnham visit to King’s Fund, see my post.

5. On Government ‘consultation’, see my post.

6. On the Choice of GP pilot, see my post.

 

 

 


Two members of Health Select Committee respond to my email on GP practice boundaries

04/10/2012

I emailed members of the Parliamentary Health Select Committee earlier in the week. I have received a reply from two of the members, Sarah Wollaston (herself a GP), and Barbara Keeley. Here are their replies:

Sarah Wollaston:

Dear Dr Farrelly,

This does look like the kind of issue that the HSC could look at but we have many outstanding and potential enquiries and the whole committee vote to decide on the order in which they are examined. I’d be happy to see this added to the list as part of the wider review of GP services and the important issue I’ve already raised of understaffing. I agree this issue of boundaries is very important.

Best wishes,

Sarah

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Barbara Keeley:

Dear Dr Farrelly,

Thank you for this, it is very worrying.

As far as I understand it, the brief of the Health Select Committee is to hold the Department of Health to account:

The Health Committee is appointed by the House of Commons to examine the policy, administration and expenditure, of the Department of Health and its associated bodies.” (quote from Committee’s page on the website)

So the matter you raise would fall within the Committee’s remit.

Best wishes

Barbara Keeley MP


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

01/10/2012

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

BA, MSc, MBBS, MRCGP
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

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


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.’

*

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 email to Lib Dems health team

21/01/2012

Dear John Pugh, Paul Burstow, and Baroness Jolly,

I emailed Liberal Democrat MPs with a question about GP practice boundaries (see below). One of your MPs emailed me to say I should address my question to the Lib Dems health team, and gave me your contact details.

Briefly, I am a GP in Tower Hamlets. I was appalled when the policy to abolish GP practice boundaries was broached in 2009; quite simply because looking after patients who live at a distance from the practice does not work (we have over the years struggled with this), and is at times dangerous; and there are a number of other reasons why it is a very stupid idea. All three major parties supported this idea.

In March 2010, I asked Andrew Lansley, then shadow minister for health, if he had any documentation to show that he had done some sort of risk assessment of this policy. In the reply that I eventually obtained, it was evident that no assessment had been made.

For the record, did the Liberal Democrat Party carry out any risk assessment or feasibility study about this issue? If yes, may I please have a copy of the documentation showing this? If not, why not?

Best wishes,

George

The Tredegar Practice, 35 St Stephens Road LondonE3 5JD

Copy by Royal Mail to Baroness Jolly; and copies in post to John Pugh and Paul Burstow


Another email to Liberal Democrat MPs on GP practice boundaries

19/01/2012

Dear Liberal Democrat MPs,

I emailed you as a group on 8/9/11 (see below). I received no answer.

The Department of Health and Andrew Lansley are now running a pilot on boundary-free general practice, and Tower Hamlets, my borough, has been chosen as a pilot site.

Let me repeat what I wrote in September:

I am writing now to put to you the same question I put to Andrew Lansley in March 2010: do you have a position paper, feasibility study, or related documentation which gives evidence that you have considered not only the benefits but also the risks of this idea [abolishing GP boundaries], and that you understand the nature of general practice (and here I mean quality general practice)?

If none of you can answer this question, can you point me in the direction of who, within the Liberal Democrat Party, might be able to help me?

Best wishes,

George

The Tredegar Practice, 35 St Stephens Road, London E3 5JD


From: George Farrelly [mailto:hearth@globalnet.co.uk]
Sent: 08 September 2011 06:19
To: ‘Adrian Sanders’; ‘Alan Beith’; ‘Alan Reid’; ‘Alistair Carmichael’; ‘Andrew George’; ‘Andrew Stunnell’; ‘Annette Brooke’; ‘Bob Russell’; ‘Charles Kennedy’; ‘Chris Huhne’; ‘Dan Rogerson’; ‘Danny Alexander’; ‘David Heath’; ‘David Laws’; ‘David Ward’; ‘Don Foster’; ‘Duncan Hames’; ‘Edward Davey’; ‘Gordon Birtwistle’; ‘Greg Mulholland’; ‘Ian Swales’; ‘Jenny Willott’; ‘Jeremy Browne’; ‘Jo Swinson’; ‘John Hemming’; ‘John Leech’; ‘John Pugh’; ‘John Thurso’; ‘Julian Huppert’; ‘Lorely Burt’; ‘Lynne Featherstone’; ‘Malcolm Bruce’; ‘Mark Hunter’; ‘Mark Williams’; ‘Martin Horwood’; ‘Menzies Campbell’; ‘Michael Moore’; ‘Mike Crockart’; ‘Mike Hancock’; ‘Nick Clegg’; ‘Nick Harvey’; ‘Norman Baker’; ‘Norman Lamb’; ‘Paul Burstow’; ‘Robert Smith’; ‘Roger Williams’; ‘Sarah Teather’; ‘Simon Hughes’; ‘Simon Wright’; ‘Stepehn Williams’; ‘Stephen Lloyd’; ‘Steve Gilbert’; ‘Steve Webb’; ‘Tessa Munt’; ‘Tim Farron’; ‘Tom Brake’; ‘Vincent Cable’
Cc: (susie.sell@haymarket.com); Lister, Sam; Mark Easton (mark.easton@bbc.co.uk); Sarah Boseley (sarah.boseley@guardian.co.uk); ‘j.laurence@independent.co.uk’
Subject: Question to Lib Dems on GP Practice Boundaries

Dear Liberal Democrat MPs,

As you will be aware, one of the policies in the Health Bill is the proposal to abolish GP practice boundaries. You may be less aware that most GPs think this is a very bad idea, and that the GPC will be resisting this ‘staunchly’ in their negotiations with the Government and Department of Health. It is said this this is to be a ‘battleground’ in the coming months.

I am a GP in Tower Hamlets. I have written to you as a group before.

I am writing now to put to you the same question I put to Andrew Lansley in March 2010: do you have a position paper, feasibility study, or related documentation which gives evidence that you have considered not only the benefits but also the risks of this idea [abolishing GP boundaries], and that you understand the nature of general practice (and here I mean quality general practice)?

I don’t know who within the Lib/Dem party is best able to answer this question so I am writing to you all.

Best wishes,

George

The Tredegar Practice, 35 St Stephens Road, London E3 5JD