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 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


My email to Peer, via 38 Degrees

06/10/2011

 

Dear Baroness Stedman-Scott,

 

I am a GP in Tower Hamlets. I have grave concerns about the Government’s Health & Social Care Bill. You will be aware of the concerns about various ingredients of this bill. I have quite a lot of experience relating to one of the Bill’s proposals: to abolish GP practice boundaries. I have resorted to writing a blog about this issue, and emailing MPs in the House of Commons. This proposal sounds like a good idea, and all 3 major parties support this policy. However, to most GPs it seems madness: this because of the nature of general practice and how it works. This proposal is simply unworkable: it will increase inefficiencies and at times be dangerous, it will cost more, and it will not deliver what it claims to be aiming for, patient choice. How intelligent people can actually champion such an idea is beyond me; but of course there is probably an underlying, unstated/hidden agenda. For a summary of the problem, with links to back my allegations, see

http://bit.ly/pMWLNb

If the Secretary of State for Health can get it so wrong for this particular issue, I have little faith in his competence and methodology to deliver a credible solution to the many challenges facing us all in the NHS. I hope the House of Lords scrutinise this Bill with care and resist proposals which lack an evidence base and will undermine the NHS.

 

Yours sincerely,

 

George Farrelly

Write to a Peer:      http://bit.ly/qLhQhM

 


An early morning email to Lib Dem MPs

15/09/2011

It’s me again, I’m afraid. I thought I better warn you about what almost certainly lies ahead with respect to the issue of GP practice boundaries.

I have never felt that this added up: from a practical point of view, it just does not make sense at all. I thought these politicians and DoH planners were just grotesquely stupid.

The reality is almost certainly one of deceipt and corruption, with the rest of politicians either complicit or just naïve.

A member of the public left a comment on my blog yesterday; he had joined up the dots, and at the end he mentioned the ‘virgin assura system of connected health centres across the UK’. I was unaware that such a thing existed. I had hypothesised that such a thing would exist in the future and that this was why they wanted to abolish GP proactice boundaries. But I woke this morning at 4am and thought I would just check, and, lo and behold, I found this.

I suggest you have a look at the leaflet that the DoH and New Labour produced  to accompany the so-called ‘Consultation’ on the question of GP boundaries in March 2010. Notice that nowhere in the leaflet, and nowhere in the larger consultation documentation, do they say: ‘and you could join the Virgin Assura system of connected health centres’, but this is in effect what the abolishing of GP practice boundaries will do. That is why they want to do it, otherwise it just does not make sense. All this talk of ‘patient choice’ is just camouflage. Just have a look at Virgin’s website, and then look at the DoH leaflet. The leaflet is a promotion of what Virgin is offering. And note that the proponents of this policy use the results of the ‘Consultation’ as evidence that the English public want this. But the ‘Consultation’ was pitched in such a way so as to produce this result, the questions are skewed in this direction.

There is really a lot more to this, and it will come out in the open in due course, I am sure. Because the media (who up to now have been crap about this issue, completely uninterested) is going to wake up soon and start shining a light on this.

Why am I writing to you at 4am? Because you people are heading off to your conference and you have been told by your leader that you cannot mention the NHS. And yet, shouldn’t you be talking about this?? Nick Clegg may have some sort of future as a Tory MP, but the Lib Dem party will have had it entirely when it becomes clear that you have been duped and used, along with the English public, as the NHS is swallowed up the the piranhas. Once they pass the law, there will be no going back.

I just thought I had better warn you.

And now I’ll have some breakfast, and then go to the surgery and see some patients, all of whom live local to the practice.

Best wishes,

George


Does the average MP understand how general practice works?

11/09/2011

On a previous post I included an email exchange with an MP. The MP had responded to one of my emails to MPs, on the topic of GP practice boundaries. The MP said: “I must say that I do have some sympathy with the idea of free registration.  I had an excellent GP in XX who I was with from the age of 19 when I went to University.  It seems strange that I could not remain with that GP when I only live 40mins away in YY.”

Now most GPs will think it is obvious why living 40 minutes driving distance (according to the AA route finder it is about 34 miles) is not practical. What is worrying is that this well-meaning MP, who is voting on the Health Bill which includes the GP boundary issue, is not aware why 40 minutes/34 miles is problematic.

What is the average MP’s understanding of the structure and ecology of general practice?


Email exchange with MP on GP practice boundaries

11/09/2011

I received the following email a few months ago, in response to one of my emails to MPs. I have been emailing one alphabetical letter at a time.

Dear Dr Farrelly,

Thank you for emailing me.  I congratulate you on your efforts to contact all MPs and taking the trouble to make sure that you semi-personalise the email.

I will read the attachments you have sent.

I must say that I do have some sympathy with the idea of free registration.  I had an excellent GP in Exeter* who I was with from the age of 19 when I went to University.  It seems strange that I could not remain with that GP when I only live 40mins away in Lyme Regis.

I would be interested in your thoughts on this.

Best wishes,

X

* [This MP did not go to university in Exeter, nor lives in Lyme Regis, and is not the MP for that area of the country; I have changed the names but the geographical distance comparable. This MP wrote in a good-natured way and was not expecting me to make this public and discuss its contents in public, and I am maintaining her/his anonymity. But I am making the contents public because I think it illustrates some important issues. I reproduce below my response.]

*

Dear X,

Thank you for responding to my email some months ago. I replied briefly at the time, and am now sending a more complete reply. I am making this public on my blog, without divulging your identity.

In your email you say that you would have liked to remain registered with the excellent GP in Exeter and that ‘it seems strange that I could not remain with that GP when I only live 40mins away’. I too have patients who move away and would like to remain registered with me. What I say to them is this: for me to offer you good care it is essential that you can get to me easily, and that I can get to you easily. With you living 40 minutes away by car, it makes this impractical. I know that it is difficult for you and that you have built up a relationship with us, but in the interests of safety and good practice I have to insist that you get a local GP near where you live.

Patients usually then acknowledge there are real practical issues, and get registered locally.

But I will illustrate this further with an example. Let us say you develop pyelonephritis; this is a kidney infection which needs urgent assessment (physical examination, urine sample) and treatment with high dose antibiotics, and often  admission to hospital. You would feel pretty ill, and might well be too ill to travel to Exeter, and I would certainly not be able to take 40 minutes to drive to Lyme Regis to assess you (80 minutes round trip, with perhaps 15-20 minutes to assess you). Now it is possible to treat pyelonephritis at home but it needs close monitoring and admission if you get worse (for a variety of reasons we would prefer to manage you at home, but this is not without risk). This is not something that can be managed over the telephone. We might well want to see you again the following day. You will understand all this cannot happen at a 40 minute’s drive distance. It simply does not work.

This is an example of an acute, serious illness (this can happen to anyone, no matter how healthy). But there are a variety of other conditions which might require regular visits to the surgery, such as hypertension: initial screening to identify the problem (are you likely to answer an invitation to have a vascular risk assessment if you have to drive 80 minutes for this, and you feel perfectly well? If you lived nearby you could drop in on your way home from work, or fit it in on a day off when you are doing some gardening); repeated visits to get your blood pressure under control; once
stable, 2 visits a year for assessment.

And if you have need of a district nurse, the team attached to your GP surgery in Exeter will not be able to visit you (at least not without a drain on their [limited]resources in terms of time). And who is going to pay for you? The PCT covering Exeter is likely to not cover Lyme Regis. So if you have a hernia repair, will this come out of Exeter’s budget (which will have been worked out for that area’s population), in which case this will be taking a (limited) resource away from the Exeter health economy; or do you set up a layer of bureaucracy so that ‘money follows the patient’? And to have your stitches removed 1 week after your hernia repair, do you drive 80 minutes for this?

One other possibly hidden systemic impact of this: all practices have a capacity limit. They can look after a given number of patients well, and if the numbers exceed this at some point quality will decline. So your Exeter GP surgery will not have unlimited capacity. If you, 40 minutes away and fit and healthy, are registered at his practice, it is possible that a person living in the GP’s practice area will not be able to register. That is, you are taking up a place that otherwise would have been occupied by a local.
(This is the way it is with our practice in Tower Hamlets: we keep the list size at 3,520 give or take; as people leave the area and the list, other local people register; if we had non-local people on our list this would be at the expense of local residents; so in our case, it does not make any sense whatsoever to register people who live at a distance from the practice and we cannot look after properly, when local demand exceeds supply).

My wife is a member of  the recently created Tower Hamlets Clinical Commissioning Group. She points out that the proposal to abolish practice boundaries conflicts with the proposal the create Health and Wellbeing Boards which are geographically based and are meant to feed into commissioning for the needs of the local population. But if we have a significant number of non-Tower Hamlets residents registered with us (commuters to Canary Wharf number ~100,000, local resident population ~30,000), where do they fit in? They will be using local resources for non-local people. And if our residents register in other jurisdictions, how are their needs assessed and commissioned for?

I could go on, and on. But I think you get the picture. Good quality general practice is a very complex technology. As a system it is local; the system works as integrated local network. To ask it to perform the same service for an expanded territory is foolhardy. It simply does not work.

In the coming months it is likely that there will be a battle between the government and the the GPC on this; then there will be anger by GPs over this. And the reason GPs will be angry is because we are being asked (forced) to do something which is unworkable, and will impact negatively on our work.

Anyway, I must stop there. Again, many thanks for taking the time to respond to my original email and in taking an interest.

I wish you all the best with your work as an MP, and life in general,

George

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For my email exchange with ‘Andrew Lansley’, click here