Getting back to work on this blog….


I have had to take a break from this blog, partly due to a 1 week holiday, and also because March is the GP ‘end of year’ so lots of deadlines fall on March 31st.

There has been lots of controversy about the Health and Social Care Bill recently. The coalition government has had to call a pause to review it. Good. But is this just a PR exercise, a strategy to turn down the heat, make some minor compromises, and then proceed?

I had set myself a goal of writing to all MPs. It is slower than I had anticipated. Today I am doing the C’s.

Email to MPs, beginning with the A’s



I have circulated this blog to everyone I can think of: local GPs in Tower Hamlets (thanks for your support), journalists, health think tanks, MPs, medical students I meet, and so on.

MPs: these were my first priority. The Health Select Committee, Health Ministers (government and opposition), and a handful of others in the first attempt (constituency MP where I live, where I work, and a few others).

Now I am emailing MPs systematically, starting with the A’s. Perhaps there is some clever way of doing a mailshot to all of them at once. I am doing it one at a time. I have a look at their photo, copy their email address, and paste it into my database as a distribution list: MPs A for tonight. I decided to type each of their names, methodically; so as to address each of them personally.

This is what I wrote:

Dear Adam, Bob, Danny, David Amess, David Anderson, Debbie, Douglas, Graham, Heidi, Ian, James, Nigel, Peter, Stuart,

I am a GP in Tower Hamlets. I am afraid my judgement at present, not without evidence, is that the political process, which includes Parliament, and the DOH, does not seem to be able to produce an intelligent management of the NHS. I am sure that most of you MPs mean well; and yet the results are lamentable, in some cases.

I have put together an argument about this which I feel does not rely on buzz words but concrete examples of problems out here (see link below).

I am circulating this to all and sundry. This is a quixotic venture. And I am including all MPs. My plan is to go through the list one letter a day, after work.

Why? Because, at the very least, you will not be able to say that nobody warned you.

 Best wishes,


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

(Rushanara Ali and Diane Abbott were included in a previous email)

Tomorrow night I will do the B’s.

The Central Question: Are they using a sound methodology?


These are feverish times. Probably not the the most propitious time for standing back and having a measured conversation.

My problems (the problem of list size and quality; the problem of patient choice of GP) are not on the agenda. And yet they are important, central to the quality of general practice and patient care.

It seems to me that the root problem here is a very faulty methodology being used to develop and implement this policy. Let me make it clear: I am not saying that all policy planning and implementation is faulty. Some of it is. Consider the following hypothetical rating scale:

Rating Health Care Policies

You will notice that I scored 10 points in the Excellent Policy box, 20 in the Good box, 30 in the Fair, 20 in the Poor. The remaining 20 out of the hundred points I put in the Kafkaesque box. That is policies which by their very design undermine quality and actually drive quality down predictably. The planners and politicians think they are doing something good, but they are actually causing harm. But they don’t know it; they don’t want to know it.

Let me outline what seems to me to be the way a Kafkaesque policy comes to life. A minister has an idea; it sounds like a good idea, something that will improve things, please the public. He goes to the DOH and lets it be known that this policy needs to be implemented, he gives it his full backing, he doesn’t want to hear any negativity, we’ve really go to follow through on this, remember I am the Secretary of State for Health, the PM is behind me on this. The DOH officials package it, dress it up with a nice cover, smiling faces, and words like Choice, Excellence, Making Things Even Better….and so on. The order goes down the chain to PCTs: implement Policy K. They might shake their heads a bit at the PCT; the primary care people (GPs, nurses) shake their heads and wonder how they can minimise the harm this is going to cause, and muddle along. There is no mechanism put in place to check how this is working. There is no way of feeding back to the people at the top, letting them know there’s a problem at the ground level.


What would a sound methodology look like? I would propose the following, just a rough outline. A minister has an idea; he takes it to the DOH; he presents the idea to the DOH people. ‘I really like this idea but I need you to evaluate it: will it work the way we hope it will?’ They gather the appropriate people to think about this, and they do an initial assessment of the idea. They ask questions like: what do we need to know in order to think clearly about this proposal; what is the aim of this proposal, what is the desired outcome; how would this work (do a walk through, modelling it); what are the unintended consequences; how might we get around the unintended consequences; and so on. Then they write up their findings in a preliminary report, and show it to the Minister. It would begin something like this: ‘We are thinking about a policy to do X. We are hopeful that this might bring about significant benefits, but we have also identified some constraints. Here is our outline:  [listing aims, benefits, costs, unintended consequences/risks, thoughts about how to avoid or minimise the risks, how it would work, how it would be implemented, etc]. [The last paragraph would be something like this]: We would be grateful for your thoughts on this. Are there any downsides or costs we have missed, are there any gains we have missed? Don’t pull any punches, we want to get this right…” And then they would send this initial draft proposal out to some sensible, intelligent, practical, straight talking people who will give their honest opinion (in the case of primary care issues, you would have a list of GPs, nurses, managers who would fit this description; not ‘yes men’, of course). These ‘experts’ would then send in their honest assessment and suggestions. The DOH people wouldthen go back to the drawing board, redraft the project proposal. They might decide that, actually, while it is an interesting idea it  will be impractical to implement (too costly, unacceptable unintended costs…), or that there are problems that need to be further hammered out, or that it all looks promising, with just a few tweaks to be made. They then present their findings to the minister, and decide on next steps. If they decide to go ahead with this, they then make the feasibility study document public: with the aims, objectives, benefits, possible risks, implementation plans etc; they would also make clear how they are going to evaluate the results of this policy. The minister would then sign the document, and so would at least one named DOH human being, with an email address for feedback. They would then implement the policy (maybe as a pilot); then they would evaluate the policy using a sound methodology which gave an honest answer and not necessarily ‘the answer they would like’. And they would publish the results of the evaluation, together with their conclusions.

This, I would submit, is a sound methodology. It is very different from the unsound methodology.


With reference to the ‘Choose Your GP’ issue, the evidence that we have available reveals a totally unsound methodology. In September 2009, the then Secretary for Health, said in a speech, ‘In this day and age I can see no reason why patients should not be able to choose the GP practice they want.’ He could see no reason, no problem with this policy. In March 2010 the Labour government, still with Andy Burnham, published an online ‘consultation’ on this issue. There was a 54 page document, a patient booklet, a patient leaflet outlining the proposed policy. Everything was slanted towards the benefits of being able to choose your GP anywhere in England. The 54 page document is full of half truths, distortions, misunderstandings of how the system actually works. It is a soothing bit of propaganda whose main message seems to be: ‘we want you to have choice, your choice, because you’re worth it….aren’t we wonderful, vote for us, your choice’ . The document mentions a few ‘challenges’, ‘but nothing unsuperable’, but leaves out numerous risks and costs. This document is truly a ‘dodgy dossier’. The questionnaire accompanying with the consultation was not designed to identify the problems, just to reinforce the message that ‘your choice is paramount’, ‘tells us what your choice is’.

I strongly recommend that you read the Royal College of General Practitioners’ response to the ‘consultation’.


What about Andrew Lansley’s methodology? I tried to find this out, and am happy to publish the result on this blog. In March 2010 I emailed Andrew Lansley. If you read the email exchanges you will see that Andrew Lansley and his team had no evidence to present that they had done a risk assessment on this policy, that they had thought it through. His chief of staff, in one of the emails, offers to ask Andrew to do a ‘feasibility study’. Well, that pretty much sums it up. A year before he was giving speeches extolling the virtues of this idea and castigating Alan Johnson for not driving it forward, and yet he has not yet done a ‘feasibility study’.

This is what I mean by poor methodology.


 To politicians I would ask: don’t pass this part of the bill until Andrew Lansley can present a properly worked out risk assessment, which shows in concrete terms how all this is going to work, in the real world. And the proposal needs to include the criticisms from those who have to implement the policy. Then if you are persuaded that this will lead to better patient care at an affordable price, then pass the bill.

Don’t be content with just lofty words like ‘Liberate’. Remember a previous occasion when Parliament agreed on a plan to do some Liberating without making sure of the facts and the complexity. There were a lot of unintended consequences.

On the loss of critical faculties



I think you will find the following a bit shocking.

 Several years ago, I think it was 2002 or so, I attended a quarterly meeting of an IT subcommittee at the PCT. During the coffee break, one of the managers asked me if I was doing any sessions in the local A+E department the following week. They were recruiting local GPs to do sessions for that week, because there was an audit, a national audit, on waiting times in A+E. I said, no, I was too busy. And thought nothing more of it until a few years later.

Perhaps in 2006 or so I was feeling particularly overloaded with demands being made on us and I found myself reflecting on how mad some of the planning was. I thought back to the A+E audit. An audit is an exercise to find out how something is working. You gather data to see how you are doing. The results then help you plan some changes in order improve things so that you can improve whatever it is you are investigating; then you repeat the audit and see if things have improved.

Now the strange thing about this A+E audit was that it wasn’t going to tell the planners how things were. It was going to tell them how things would be if you hired extra doctors to do the job. Now I am assuming that this audit was meant to answer the question, ‘How are we doing?’ and not ‘How would we do if we hired extra doctors and pulled out all the stops?’

 So an audit was performed; extra money was spent; the results purported to show you how the ‘normal’ service performed, but in reality told you how things would work if you hired extra doctors and did the best you could for a week. The shocking thing is this: you think you are checking on how things are, you are given results. You presumably use these results to plan things. So the results are in reality misleading: they make you think you a doing better than you are, and you have spent extra money to get this wrong data.

This is pretty shocking. But what is also shocking is that at the time I thought little of it. I did not say, ‘This is mad.’ I didn’t even think it. Nor did my colleagues, whom I viewed as thoughtul people.

 And I have observed further anomalies over the years which have been a bit mad, and otherwise sensible, thoughtful people not challenging it but just getting their heads down, and getting on with it.

And so I posited an explanation for this: infection with LCFV (Loss of Critical Faculties Virus). What this infection does is dulls your critical faculties so you become slow-witted, accepting of whatever you are presented with, and you just get on with it.

Once you become aware of this terrible virus, things begin to make sense.

On the Kafkaesque



Kafkaesque: you may be familiar with this term. Not everyone is. I sometimes say to a patient who has brought me a particular type of problem, ‘Do you know the meaning of Kafkaesque?’ Many do not. I then explain that it is a situation where a person feels in a nightmarish situation: they are standing in a queue for hours; then are told that they are in the wrong queue, that they need to go to Section 7 and wait for further instructions; they go to Section 7 and wait; nobody comes for them. They ask for guidance and are told they should not be in Section 7, how silly of them to come to Section 7, they need to be in Section 9a; they go to Section 9a and find a sign which says: ‘Section 9a is closed for refurbishment, please go to Section 7 and await further instructions’. And so on; you get the picture. Patients are usually helped by being aware of this term and its meaning: at least someone has described this, recognised this; they are not alone.

Like the patient who has quite severe, enduring depression; he has seen psychiatrists, is on medication, but feels dreadful, hopeless. He feels physically exhausted and spends a lot of time in bed. He feels ashamed of his inability to get going. He goes to the DWP medical examination (with great effort), and is told, in a letter that arrives a week or two later, that based on the examination (one test was to see if he could fold a piece of paper and put it in an envelope) he has been deemed fit for work, and that his benefit (including his housing benefit which is paying his rent) has been stopped. This is a true story, incidentally, and occurred recently. This is Kafkaesque. The patient appealed the decision; then waited several months (benefits cut off); when he went to the Tribunal they apologised and re-instated his benefit. (In a truly Kafkaesque situation, they would have turned down the appeal….)

The writer Borges said this: ‘Kafka’s most striking talent was for inventing intolerable situations.’

Yes, intolerable situations. Our situation with having to register all patients was Kafkaesque.

The policy of registering with whatever GP you would like, anywhere in England, is Kafkaesque.

That nobody is discussing this policy is, in itself, also Kafkaesque. When I asked about this at a GP meeting a few months ago, I was told, ‘Yes, it is a crazy thing but all 3 parties are in favour of it so there’s nothing we can do.’ They are all worrying about how we are going to form Consortia, grapple with a limited budget, and so on.