It is now crystal clear: the Choose your GP Pilot ‘independent evaluation’ in no way evaluates the actual policy

12/04/2014

Yesterday the practice manager of a large Tower Hamlets practice (and CCG Board member) and I went to meet with Professor Nicholas Mays and two other authors of the Evaluation of the choice of GP practice, 2012-13 at the London School of Hygiene and Tropical Medicine.

We outlined the reasons why abandoning practice boundaries in Tower Hamlets would not be in the interests of our aim to provide good quality primary care services to our local communities. Quite to the contrary, why it would be harmful and destabilising.

We had an interesting conversation about the pilot, about the various competing aims, about unintended consequences, about politicians, and about pilots.

I believe their report is well written and contains a number of important points, and they have done a serious piece of work. But they were clear that their evaluation only evaluates the pilot, and not the policy. The pilot had small number of patients and in no way ‘tested’ the policy; in fact, the sorts of risks I have highlighted in my Submission to the Health Select Committee are not revealed by the pilot, they are hidden. (I expressed these concerns in an article for Pulse in December 2012.)

It is as though you invited smokers over the age of 70 to meet you at the top of a tall hill, and you asked them if they liked smoking and if it had impacted negatively on their health. It is likely that they would say that they enjoyed smoking, and it caused them no problems (hence their age and ability to get up the hill). You might conclude that smoking was a harmless pleasure.

 


My concerns about the ‘independent evaluation’ of the choose your GP practice pilot

11/01/2014

I have written to the current Secretary of State for Health, Jeremy Hunt, about my concerns about the proposed policy to abolish GP geographical boundaries. To my first email, I received a non-reply masquerading as a reply and so I sent a second email. The reply to this second email was no better than the first and in fact covered much the same ground as the first reply. So I have emailed him again today. (I have sent similar emails to NHS England and the CQC; NHS England’s reply was wholly inadequate so I have written to them again).

The replies I have received so far have limited themselves to describing the structure and process of the Pilot (which ran from April 2012 to April 2013), and the fact that an ‘independent evaluation’ would be made, and sent to the relevant bodies, including the GPC and NHS England (who have inherited the responsibility for implementing (or not) this policy).

I have been sceptical about this policy from the beginning, and my scepticism has if anything grown over time. The policy sounds attractive at first sight, but to anyone who knows how general practice in the UK works (its ecology), the policy does not make sense. The Department of Health so far have promoted this policy assiduously, ignoring the problems and risks. The 2010 ‘consultation’ was a PR exercise, structured in such a way so as to get the desired result, a New Labour ‘dodgy dossier’. The politicians and Department of Health have since used the ‘results’ of this rigged consultation to continue to push for this policy.

The Pilot structure did not actually test the policy itself in any true sense. I wondered how the evaluation would be structured: I thought it likely that it would avoid evaluating the policy itself.

I contacted Professor Nicholas Mays of The London School of Hygiene and Tropical Medicine, and Director of the Policy Research Unit in Policy Innovation Research who were commissioned to carry out the evaluation. I asked Professor Mays if I could see the ‘spec’ the Department of Health had sent them; he did not have such a document, but sent me the Evaluation of GP practice choice pilots, Proposal, 14 May 12 that he had submitted to the Department of Health in response to their request. He suggested I contact the Department of Health about the specification and so on. What I found out was that the Proposal was the result of a meeting between Department of Health officials (I do not know how many) and Professor Mays (I do not know if other members of the Policy Research Unit were present). The Pilot was discussed at this meeting, and the Proposal resulted from this discussion. The meeting was not minuted. So no written ‘spec’.

I read through the Proposal and it confirmed my fears. The evaluation was designed to assess the Pilot rather than the policy. This sentence is from the first paragraph, under the heading ‘Rationale’:

“According to the Department of Health, 75% of patients who responded to a recent consultation on GP choice made it clear that they wanted greater ability to register with a practice of their choice irrespective of its location.”

This is the ‘consultation’ which I say is rigged. Has Professor Mays read the consultation documents and assessed how this ‘75% of patients’ was engineered?

Further along in the Rationale section is the following:

“People able to access GP services in the pilot areas will have greater choice and flexibility about the GP practice that provides their personal care. It will mean patients are able to register close to work, close to a relative they care for or even close to a child’s school.”

This detail, ‘even close to a child’s school’, bears further scrutiny. It was one of the avowed benefits of the pilot (and therefore the policy) in the Department of Health’s media launch in December 2011. I wonder if the evaluation will scrutinise this detail. Will it ask if this detail, registering with a practice near a child’s school, actually makes sense? What benefit accrues from this? How does it work? Are there any risks? Did Professor Mays’ team ask these questions, or did they just take this as a given?

I replied to Professor Mays as follows (19/10/13):

“I have now read through your Proposal for the Evaluation of GP practice choice pilots. It confirms what I feared. Your evaluation does not actually scrutinise the policy itself. I am not criticising you or your team but I think the DH has given you a brief which means that you avoid asking some very basic questions. I am sure that you have done good, thorough work, and I am sure you will come up with some interesting and useful insights; but it is likely that your ‘evaluation’ will miss the basic, fundamental flaws of this policy. These flaws are not exposed, revealed, by the ‘pilot’.

I attach my Submission the the Health Select Committee of May 2013. It outlines what I see as the main problems, I hope in a clear way. I suggest you and your team read this document.

What I am saying is that this policy has been promoted without taking into account the problems, the side effects, the unintended consequences, and it would appear that this has been done intentionally, wilfully. When thalidomide was launched in the late 50’s, it was marketed as a wonder drug, and there were real benefits. But there were also very considerable problems, which emerged with time.

Your evaluation will, by its very design, concentrate on the benefits of thalidomide, the marketing and distribution strategies of thalidomide, but not with the unwanted side effects.

I know what the problems are with this policy, I deal with them on a daily basis, and what I have outlined in my Submission is just the tip of a large iceberg.

I would be happy to meet with you to discuss this further, if you think that would be constructive. I am copying this to the GPC.”

*

I have not yet been able to see the final report that was sent to NHS England and the GPC. Professor Mays has told me it is being peer reviewed and then will be available, perhaps in the next month or so. Once I have read it, I hope then to meet with Professor Mays to discuss this further.


NHS Choices Website: my attempt to leave a comment regarding ‘Patient Choice Scheme’

14/04/2013

A few weeks ago, I found the NHS Choices page promoting the ‘Patient Choice Scheme’. I registered and left this comment:

I am a GP in Tower Hamlets, one of the sites chosen for this pilot. What the Department of Health is not telling you is that two of the 6 sites above (Tower Hamlets and City and Hackney) have refused to take part in this pilot in order to protect the local health economy and services to our local population.

The proposed policy to abolish GP practice boundaries is deeply flawed, but the Department will not tell you that.

For more information, see www.gpboundaries.org

*

I checked this afternoon, and noticed that my comment (which I thought had been accepted on 31/3/13) was missing. There are in fact no comments to this page. So I have tried again. My Comment on Choices website but somehow feel that it won’t be visible, ever, to anyone else.


Message for GPs: Consider signing petition for Health Select Committee about GP boundaries

03/03/2013

The Coalition Government is clearly intent on abolishing on GP practice boundaries: in their Interim Review they recently listed the GP boundary-free pilot as one of three areas that showed that they had ‘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. (page 24)

This is a most misleading claim: in reality 2 of the 6 PCTs have boycotted the pilot; of 345 GP practices in these PCTs, 42 practices have opted in to the pilot; at a recent count, 514 patients had registered with a practice, more than half in the London Borough of Westminster. These are small numbers. The DH and Government say they are going to ‘independently evaluate’ this pilot, but I fear that this will mean merely asking those (few) patients who registered with a practice how they found the experience. Of course, they will say they liked the opportunity to choose a practice near work, etc. The evaluation will almost certainly not evaluate or comment on the merits of the policy as a whole.

What can GPs do? I have written a series of articles for Pulse on this issue, and the 6th article addressed this question.

One thing we can do is to put pressure on the Health Select Committee to scrutinise this policy carefully. This would shine a light on the policy, the way it has been promoted with groundless and bogus claims, the way the public and Parliament have been misled, the way in which it will harm primary care in England.

If you are a GP, please sign the petition calling on the Health Select Committee to investigate the policy.

 


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.


1. This really has to stop

05/06/2012

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

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

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

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

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

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

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

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

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

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

But it really has to stop.

 


‘Choose Your GP’ pilot: a confidence trick?

04/06/2012

4/6/12:

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

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

“Busy commuters will benefit the most from the new pilot scheme, which allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

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

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

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

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

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

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

Report on City of London primary care needs

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


My email to ‘Choose Your GP’ pilot enthusiast

04/06/2012

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

A Westminster GP Ruth O’Hare said:

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

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

*

I emailed this GP as follows:

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

Dear Ruth O’Hare,

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

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

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

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

Many thanks.

Best wishes,

George

The Tredegar Practice 35 St Stephens Road London E3 5JD

www.onegpprotest.org

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


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

Dear George,

I have discussed your email with local colleagues.

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

Best wishes

Ruth


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

Dear Ruth,

I would have replied earlier but have been away.

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

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

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

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

Best wishes,

George

The Tredegar Practice 35 St Stephens Road London E3 5JD

www.onegpprotest.org

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


East London LMCs advise boycotting ‘Choose Your GP’ pilot

21/04/2012

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

My comment to the Pulse article:

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

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

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

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

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

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

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


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

08/01/2012

The Government and Department of Health recently announced pilots for commuters to be able to able to register with GP practices near their place of work. Tower Hamlets, City and Hackney, and Westminster are amongst the pilot sites.

There was an article in Pulse this past week which quoted some of the misgivings of affected LMCs (Local Medical Committees).

I posted the following comment to the Pulse article (as well as the similar story in GP Online):

I have been thinking about this issue for some time now. I know that a minority of GPs are ‘excited’ by it, but I am not clear why. I practice in Tower Hamlets; when people move away, it becomes in many ways unworkable to continue to look after them as patients. This has been our experience. Yes, there are some groups of patients who need a workable solution: use a sensible methodology to find that solution, but be clear-headed and honest about the risks and problems.

I fear that this whole ‘Choice’ issue is just a Trojan horse. The Choice offered is an illusion, and hidden within this horse are all sorts of problems, unintended consequences, anomalies. I hope in the coming months this issue will be aired, the deceptions made clear. It is essentially a fraud. The ultimate aim (covert) is the de-regulation of English general practice. De-regulation in the sense that financial services were (under concerted pressure from lobbyists) de-regulated, leading to financial gains for some, but (undeclared) risks and subsequent losses for many clients. General practice without boundaries is, I think, the Holy Grail for some. But it won’t give us good quality, community based, integrated, family medicine. Indeed, it will undermine it.

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