My emails to NHS England about the new GP boundary-free policy implementation

15/02/2015

[Names have been redacted to protect the innocent]

From: Farrelly George (NHS TOWER HAMLETS CCG)
Sent: 09 January 2015 18:26
To: ***** (NHS ENGLAND)
Cc: Farrelly George (NHS TOWER HAMLETS CCG)
Subject: out of area patient registration

Dear ****,

I am a GP in Tower Hamlets. At present, on the NHS Choices website, there appears to be no clear guidance as to which practices are actually opting into this service. Unless I am missing something, patients have no way of knowing which practices are offering this without ringing practices one by one.

We are not offering this because we do not feel it is workable, but if patients approach us we would like to have something to offer them in the way of signposting participating practices.

Best wishes,

George

The Tredegar Practice
35 St Stephens Road
London E3 5JD

*

From: ****** (NHS ENGLAND)
Sent: 15 January 2015 09:33
To: Farrelly George (NHS TOWER HAMLETS CCG)
Cc: ****** (NHS ENGLAND); ***** (NHS ENGLAND)
Subject: FW: out of area patient registration

 

Dear George

Thank you for your e-mail and please accept my apologies for the delay in responding to your query.

We currently don’t hold a central list of those practices that have expressed an interest in delivering out of area registration for patients, however, area teams have been provided with information via the e-declaration of those practices that indicated an early interest in the scheme so you may wish to contact NHS London who should be able to provide you with further information of local practices who may register patients out of area.

If I can provide any further assistance please do not hesitate to contact me or one of my colleagues.

Best wishes

******

******
******NHS England | 4E60| Quarry House | Leeds | LS2 7UE

High quality care for all, now and for future generations

 

*

Email George Farrelly to NHS England, London; 23/1/15; 08:22

 

Dear NHS England London (North East Area Team),

I sent the following email (see above) to NHS England and you can see from this email thread that they have suggested, for the situation in London, that I contact you. I have a number of reasons for wanting to know how patients are to find practices that are signed up to registering patients who do not live locally (one is to direct patients who enquire).

“I am a GP in Tower Hamlets. At present, on the NHS Choices website there appears to be no clear guidance as to which practices are actually opting into this service. Unless I am missing something, patients have no way of knowing which practices are offering this without ringing practices one by one.

We are not offering this because we do not feel it is workable, but if patients approach us we would like to have something to offer them in the way of signposting participating practices.”

Do you have a list of London practices (or north east London practices) who have expressed an interest or have signed up to registering patients who live out of area?

You can reply to this email, or if you prefer my mobile is ***** *** ***.

Best wishes,

George

*

Email George Farrelly to NHS England, London; 23/1/15; 09:08

Dear NHS England London,

I now have an additional question which relates to the other side of the coin: that is, patients who are resident in Tower Hamlets but have registered with a practice in, say, Ealing near where they work.

If that patient gets ill and is stuck at home on Tower Hamlets, the new arrangement is that they access a Tower Hamlets GP who is providing an enhanced service to these sorts of patients. But who is providing this in Tower Hamlets? (A recent Pulse article has suggested that the Out of Hours service might be called upon to provide this service, but that would mean they would have to be operating In Hours as well….). I will be speaking to our out of hours service shortly….[I spoke to the Tower Hamlets out of hours service; they had not been approach to provide in hours cover]

My understanding is that NHS 111 would have that information.

I have just rung NHS 111 covering Tower Hamlets but the helpful nurse advisor I spoke to was unaware of the new policy; she could only suggest that a Tower Hamlets resident without a local GP would have to go to a walk in centre or to A+E. She spoke to her supervisor who was also unaware of the new policy and where such a patient might be directed.

Can you help? (Can I say I sympathise with your situation: you did not dream up this policy but you have been given the task of implementing it….).

Again, my contact number is ***** *** ***.

Best wishes,

 

George

*

15/2/15: I have not had a response from NHS England London.

I have since contacted NHS 111 for Islington where I live and they also did not know about the policy and they gave the same answer as NHS 111 for Tower Hamlets. I then rang NHS 111 for central London (this includes Chelsea and Westminster, Camden, Hammersmith, and others); they too are were unaware of the new policy and did not have a list of local GPs who could offer In Hours care for patients not registered locally.

*

12/6/15 update: I still have not had a reply from NHS England. I emailed Jeremy Hunt about this problem as well. The Department of Health gave a characteristically evasive and meaningless reply, but noted that I had written to NHS England.

A few days ago, I checked again with NHS 111 for Central London. The supervisor did not have an accurate understanding of the GP Choice Policy, and said there was no infrastructure in place to provide primary care services to local residents not registered with a local GP. They were not in a position to arrange visits to those requiring them, or consultations with local GPs. They would be advised to go to a Walk In Centre or to A+E.

 


How does registering with a GP near your child’s school benefit you? Question to CEO of Patients Association

28/06/2014

28/6/14

Dear Katherine Murphy,

I am a GP in Tower Hamlets and have been following the Government’s policy regarding GP practice boundaries with some bewilderment over the past 4 years. I became aware that the Patients Association was also keen to abolish GP practice boundaries in the interests of giving patients more ‘choice’. You will of course be aware that the policy will be rolled out in England, on a voluntary basis, from October 2014.

My difficulty has been that the proponents of this policy do not seem to take into account some very practical problems inherent in the policy, and have made claims for the benefits of such a model which simply do not add up.

One suggested benefit will be that patients will be able to register at a practice near their child’s school. The Department of Health mentioned this in their December 2011 launch of the Choose Your GP pilot, you mentioned it in your Huffington Post posting in March 2013, it is mentioned in the first section of the Proposal by the team who then evaluated the pilot, and it has been repeated in the press.

I question the wisdom of this proposal and have asked Jeremy Hunt, the Department of Health, and NHS England the questions below, but they have not answered me. Because you have also gone on the record publicly proposing this as one of the incentives, can you please give an answer to the following questions:

a. what benefit accrues to a child or parent(s) by registering with a GP practice near their child’s school? What might they be hoping to gain from this? Does this mean a parent registering with the practice, or the child, or both? Would all the children of the family register with the practice? Would both parents, in two parents families, register with the practice?

b. how would this work from a practical point of view? When would they want to be seen? How would they make appointments?

c. what, if any, are the possible risks or drawbacks with this arrangement?

I would be grateful for your comments on this.

 

With best wishes,

George

The Tredegar Practice
35 St Stephens Road
London
E3 5JD

*

24/7/14

I have not heard from Katherine Murphy or the Patients Association. I wonder why….

Is it the same reason why the Department of Health has not answered these questions, or NHS England?

*

12/10/14

I have just sent the following email to the Patients Association:

Dear Katherine Murphy,

I sent you the email above on 28/6/14. I have not received a reply, so I am trying again. I will send this in the post as well in case there is some glitch in the system.

Best wishes,

George

The Tredegar Practice
35 St Stephens Road
London
E3 5JD

[the above items sent in Royal Mail 24/10/14]

*

My email to The Patients Association in June 2011.


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.

 


Department of Health response to my second email to Jeremy Hunt

24/01/2014

This is the Department of Health’s ‘response’ to my second email to Jeremy Hunt:

Our ref: DE00000813924

Dear Dr Farrelly,

Thank you for your further correspondence of 13 October to health ministers about the removal of GP boundaries in six primary care trust (PCT) areas .  I have been asked to reply.

I am sorry that you were dissatisfied with the Department’s previous response (our ref: DE00000807059).  However, there is little I can add on the matter.

With many people working some distance from home, it is not always convenient for them to see a GP in the area in which they live.  The piloting arrangements were introduced to allow patients, who wished to do so, to register with a practice away from the area where they live, perhaps closer to where they work.  Arrangements are in place to ensure that, should patients wish to register away from home, they are still able to access primary medical services should they need them when at home.

The arrangements were trialled in a limited number of areas and the results have been evaluated and passed to NHS England.  It will be for that body to decide whether they wish to roll out the arrangements on a wider basis.  Should you wish to raise your concerns with NHS England, you can do so at the following address:

NHS England

PO Box 16738

Redditch B97 9PT

Tel: 0300 311 22 33

Email: england.contactus@nhs.net

I am sorry I cannot be more helpful on this occasion.

Yours sincerely,

Lindsey Cox
Ministerial Correspondence and Public Enquiries
Department of Health


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.


I smell a rat. Is Monitor working in the interests of patients or free market healthcare?

27/10/2013

I recently set up a Google news alert for articles on GP practice boundaries.

It threw this article up this morning.

“Monitor senior policy adviser Paul Dinkin, the man heading its primary care consultation, said his initial conclusion was that Monitor would play a major part in primary care.”

“Mr Dinkin said his review was looking at barriers to entry into general practice, such as practice boundaries and registered lists.”

“He said the BMA and the RCGP were wrong to say general practice needed more funding. ‘Our suspicion is not more money for the current model, but to rethink who does what.'”

And my suspicion is that Mr Dinkin does not know a great deal about the ecology of general practice, and that he has little interest in finding out.

Checking on the Monitor website, I found a Call for evidence on general practice services sector in England.  Issued on 1 July 2013, deadline for responses 1 August 2013. So I won’t be offering my views.

Who is Paul Dinkin and what is his background? I could find precious little online. Even on Monitor’s website there is no information.

Can we have some transparency, please?


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

13/10/2013

Dear Jeremy Hunt,

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

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

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

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

*

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

Notes:

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