14. How can they be so stupid? The Plot Against the NHS

05/06/2012

[This is the 14th in a series of 14 posts. I suggest you scroll down and start with Number 1]

The Plot Against the NHS is a book by Colin Leys and Stewart Player; I would recommend it, read it and judge for yourself.

Briefly, their thesis is that a ‘concordat’ was negotiated in 2000 by the Independent Healthcare Association with Tony Blair’s second Secretary of State for Health, Alan Milburn. ‘The Association’s leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, “to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers.”‘ (page 1)

The authors document the steps that were taken to further this aim. They call it a plot because it was covert, never made explicit, never debated. ‘Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage.’ (2)

Some excerpts:

‘So in spite of it great popularity Britain’s most famous postwar oscial achevement was unravelled through a series of step-by-step ‘reforms’ each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn the health care back into a commodity and a source of profit.’ (5)

‘Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘speacil advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Select Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.’ (5)

‘Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.’ (5-6)

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These are just a few excerpts. I have bought and read the book. To me it helps make sense of DOH behaviours which are otherwise mind-bogglingly stupid.

If you understand the ‘Choose your GP’ policy as aiming to de-regulate English general practice and open it up to for-profit companies, then it is rather clever, not stupid. But it does rely on the public being duped, and not seeing through the duplicity and deception; and the journalists, and the GPs, and other health professionals.


11. How can they be so stupid? Cognitive Muddle

05/06/2012

At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.

It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’

So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’

Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.

Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.


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

05/06/2012

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

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

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

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

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

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

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

DOH ‘Media Centre’ Launch

Two examples (there are at least 5 others):

Oxford Times ‘article’

Express ‘article’


8. How can they be so stupid? Duplicity

05/06/2012

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

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

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

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

Health Secretary Andrew Lansley said:

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

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

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

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

(For text of what he said to RCGP)


7. How can they be so stupid? Deception

05/06/2012

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

Wikipedia is much richer here:

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

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

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

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

For full Wikipedia article on deception

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


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

05/06/2012

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

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

Naivety

Ignorance (wilful and unwilful)

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

Misinformation (wilful and unwilful)

Deception

Duplicity

Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)


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

18/09/2011

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

In essence the issues are as follows:

The proponents of the policy argue that:

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

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

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

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

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

What is the evidence?

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

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

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

But why would they want to do it?

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

What can we as GPs do?

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

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

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

[Your views are welcome, comment below]

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Links to documentation:

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

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

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

If you read this leaflet, why refuse the offer?

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

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

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

5. Concrete examples  from our everyday work.

6. Miscellaneous:

My email exchange with The King’s Fund

My email to the Patient’s Association

My email to an MP

Is this the future? Virgin Assura Medical

Strategy of US for profit companies: read this

Trust in professionals poll 2009


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


The Department of Health’s response to my concerns about GP practice boundaries

11/09/2011

In January 2011 I began emailing MPs, one letter at a time (all the A’s, then the B’s, etc); & I copied the health ministers in as well. I then received an email from the DoH; a long disquisition on the White Paper, and the Bill which intended to ‘modernise’ the NHS. It said nothing whatsoever about practice boundaries. So I emailed the ministers, saying, among other things, this: ‘…your response is not really a response to my concerns at all. It is as though I had asked how to get to Bristol
from London by train and you had sent me a recipe for a cheese omelette.’

A few hours later I received this email:

21/2/11

Dear Dr Farrelly,

Thank you for your email of 31 January to Anne Milton about GP practice boundaries. I have been asked to reply.

The Government’s proposals for greater choice of GP practice are designed to reflect the central importance of general practice in providing continuity of care for those on their registered lists. The Department of Health knows that the majority of people are happy or very happy with their local GP practice and with the continuity of care that it provides. But the Department also knows that a significant minority have no choice but to register with a practice that they then rarely use because of difficulties of access, or because it does not provide a responsive service. Some of these people rely instead on using a mix of Accident and Emergency services, walk-in centres and other urgent care services. The Department’s aim is to ensure that everyone is able to register with a practice that provides genuine continuity of care.

The Department does not envisage that many patients will want to want to choose a GP practice a long way from where they live. There will clearly be many cases, particularly for people with complex health problems, where it makes obvious sense to choose a nearby GP practice. The Government thinks it wrong, however, to prevent people from registering with a practice (for example, one near to their place of work) where they have made an informed decision that this will provide the best and most responsive service for them.

On 4 March 2010, the Department of Health initiated a consultation to seek people’s views on proposals to abolish GP practice boundaries so that people can register with a GP practice of their choice. The consultation closed on 2 July and attracted over 5,000 responses from members of the public and clinicians, which shows how important an issue this is to so many people, patients and NHS staff.

The responses show that over three-quarters of the public want to be able to choose their GP practice and do not want this ability constrained by practice boundaries. Many GPs and NHS colleagues have raised issues about how opening up choice will work in practice, and the Department of Health is working through these issues with professional and patient groups and with the NHS. The Department published a summary of the responses on 18 October 2010, which is available on its website at:

www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_120283

The Department plans to set out a more detailed plan of action shortly that will look at the arrangements that the NHS will need to put in place over then next year. The Government is confident, however, that it can do this in a way that not only preserves the strengths of general practice and registered lists, but enables everyone (not just the majority) to benefit from these strengths.

I hope this reply is helpful.

Yours sincerely,

X

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My Response (copied to the health ministers, and members of the Health Select Committee):

Dear X,

Thank you for your response to my concerns. I would have answered sooner but have had to keep up with the day/evening/weekend job. I am afraid that you are up against a technical problem which cannot be eliminated by wishful thinking or sound bites. By ‘technical’ I mean things like gravity, not being able to be in 2 places at the same time, the fact that it takes time to get from A to B, that there are limits to how many travellers can (safely) fit on a plane, that if you try to walk across the Channel to get to France you will sink in the water. Your bosses and the politicians have just ignored the technical aspects of their proposal. Just as technical aspects were ignored or wished away in the invasion of Iraq. The trouble, in the real world, is that the technical persists.Would you want to work in a skyscaper that was built by dreamers? Perhaps designed by dreamers, yes, but then cleared by feet-on-the-ground structural engineers and built by professionals. May I suggest you read The Checklist Manifesto by Atul Gawande (a surgeon); pages 70-1 if you are in a real hurry.

In 1991 when my wife and I were interviewed by a panel in order to take on the responsibility of our present practice, one of the questions we were asked was, ‘What are you going to do about the outliers on the list?’ Outliers were patients who lived outside the practice area (some at a fair distance). Because at that time it was felt that to have patients living at a distance from the practice was ‘poor practice’, that it led to poor care. This was for technical reasons. We explained how we would deal with
this. We had to write to a number of patients who lived at some distance from the practice and ask them to get a local GP. They would have preferred to stay on the list, for their own reasons, that would have been their ‘choice’. It took extra work to do this, why do it?

The technical aspects which pertained then have not changed, they are pretty much the same. You cannot escape from that, that’s just the way the world works. The Department of Health and politicians have alluded to practice areas as an outmoded irritation, ‘constraining choice’. I assure you, there are perfectly sound, practical, reasons for ‘practice boundaries’. I have learned this over my 20 years in Bow. I see it every day.

Why am I spending time on a Saturday night writing to you, spending time with this issue? I would much prefer to be reading a book, watching a film, seeing friends. I am spending time on this because there are real reasons why what your bosses and the politicians are planning will lead to an undermining of good quality British general practice. And this is tragic. If we end up, 10 years from now, with a US-like model of primary care, that will be an incredibly retrograde step.

I do not have the time right now to respond to each of the points in your email. I will do so when I have time. I am not persuaded by your arguments. I certainly accept that we should aspire to providing good quality general practice to the whole population, but your bosses’ plan will not achieve this. The so-called Consultation which you allude to I view as a dishonest PR exercise. I hope to get the time to show why. Perhaps check my blog in a month or so.

Perhaps you truly believe what ‘The Department’ are doing. It may be that you think it is a bit crazy, but you have to pay the mortgage. I would not blame you if that is your position.

Best wishes,

George


A helpful criterion from physicist Richard Feynman

02/07/2011

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

This morning I read an article in the New York Review of Books: Freemon Dyson reviewing two books about the physicist Richard Feynman. Dyson relates one episode towards the end of Feynman’s life. Feynman was invited to be part of the NASA commission investigating the space shuttle Challenger disaster of 1986 (the shuttle broke apart a minute after take off, resulting in the death of the 7 astronauts on board).  Feynman was ill with cancer at the time, and did not have long to live: ‘He undertook it because he felt an obligation to find the root causes of the disaster and to speak plainly to the public about his findings. He went to Washington and found what he had expected at the heart of the tragedy: a bureaucratic hierarchy with two groups of people, the engineers and the managers, who lived in separate worlds and did not communicate with each other. The engineers lived in the world of technical facts; the managers lived in the world of political dogmas.’ Feynman found that these two groups had very different views of the levels of risk: the engineers estimated the risk to be one disaster in every 100 missions; the managers estimated the risk as one disaster in 100,000 missions. There were two main causes of the disaster: a probable direct technical cause (a rubber O-ring seal which malfunctioned at cold temperatures), and a cultural cause. ‘The political dogma of the managers, declaring risks to be a thousand times smaller than the technical facts would indicate, was the cultural cause of the disaster. The political dogma arose from a long history of public statements by political leaders that the Shuttle was safe and reliable. Feynman ended his account with the famous declaration:

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

I am very happy to have found this sentence for it helps to clarify the situation which confronts us with the issue of GP practice boundaries (and of course the many other complex issues surrounding the NHS, and the so-called ‘reforms’).

Can we please allow reality to take precedence over public relations? Can the politicians and DH please do a sensible and honest and public RISK ASSESSMENT of the complex technology that is UK general practice, and the function of practice boundaries? And of the technical problems which come into play when people live at a distance from their registered GPs? 

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New York Review of Books article  (unfortunately, you cannot read whole article without a subscription)

Challenger Disaster  (Wikipedia; a salutary read)