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.


Tower Hamlets CCG Chair letter to local MPs on Section 75 Regulations

09/03/2013

2nd Floor Alderney Building

Mile End Hospital

Bancroft Road

London E1 4DG

Jim Fitzpatrick MP

Rushanara Ali MP

1st March 2013

Dear Jim and Rushanara,

Re: Section 75 Regulations and EDM 1104 (Early Day Motion)

We are extremely concerned about the regulations to bring into effect Section 75 of the Health and Social Care Act.

As commissioners we are determined to use all of the tools at our disposal to deliver the highest quality services for our patients and the people of Tower Hamlets.  To do this, we need to be able to commission integrated services which place the patient in control and provide a seamless passage across health and social care and through different health services.

Our view is that clinical commissioners must be provided with the freedom to use the full range of procurement tools including integration, collaboration, innovation pilots and a variety of competitive tendering mechanisms where appropriate. These must be based on achieving the highest quality and best value for patient outcomes rather than price alone, and give appropriate weighting to delivering the best care.  To do this we need to be free to choose what the most appropriate tool for any given situation is. Our concern is that the regulations laid under Section 75 of the Health and Social Care Act will be interpreted in a way that will obligate commissioners to carry out virtually all commissioning through competitive tendering.  This may negatively affect the way that seamless care can be delivered.

It is essential that CCGs are given greater freedom to choose when and how to procure new services and that the risk of referral to Monitor or the courts does not place a chilling effect on commissioners’ ability to take a more inclusive route if that is what they feel is best for patients, especially in relation to the care of complex patients, where services may be best provided by a small number of connected providers.

We all know that we face massive financial challenges in the NHS combined with managing a new system that has separated Primary (General Practice), Secondary (Hospitals) and Tertiary (Specialist) commissioning.

We do not underestimate this challenge and are determined to provide a high quality service for all our patients. Restricting our options will reduce our ability to provide the best for our patients and make it so much more difficult to manage the financial challenges.

I hope you feel able to support EDM 1104, which calls for a full debate on the issues raised by the Statutory Instruments laid under Section 75 of the Health and Social Care Act.

Best wishes

Dr Sam Everington

Chair

NHS Tower Hamlets CCG


Tower Hamlets CCG opposes Health and Social Care Bill

28/02/2012

The Tower Hamlets CCG (Clinical Commissioning Group), having conferred with the GP body in Tower Hamlets, have sent the following letter to David Cameron. See text below; see the actual letter here CCG letter opposing Health and Social Care Bill.

Tower Hamlets Clinical Commissioning Group

27 February 2012

The Right Honourable The Prime Minister

10 Downing Street

London

SW1A 2AA

Dear Prime Minister

The Board of NHS Tower Hamlets Clinical Commissioning Group ask you to reflect and to withdraw the Health and Social Care Bill.

Supporting improvements in the quality of patient care is our passion and focus. We support a strong role for clinical involvement in commissioning decisions that lead to better health outcomes for our patients. We do this already in Tower Hamlets.  An Act of Parliament is not needed to make this happen.

Tower Hamlets Primary Care team has a long tradition and reputation for innovation and commitment to partnership working with patients and managers. We make the best of any challenges that come our way. Innovations include real improvements in the health of our patients with chronic illnesses like diabetes, the highest childhood vaccination rates in London, and an exemplary local out of hours service, delivered by our GPs and highly valued by patients.

We work in partnership with the community, hospital, local authority and community organisations, to improve and integrate services for the benefit of our patients. It is against this background that we represent the views of our local GPs in asking you to withdraw the Bill.

You are familiar with the submissions on the long-term implications of the Bill made by our professional representative organisations, the Royal College of General Practitioners and the British Medical Association. We share their concerns.  We add to that our own experience. Clinicians, patients and managers in Tower Hamlets are determined to improve health and well-being, but your rolling restructuring of the NHS compromises our ability to focus on what really counts – improving quality of services for patients, and ensuring value for money during a period of financial restraint.

We care deeply about the patients that we see every day and we believe the improvements we all want to see in the NHS can be achieved without the bureaucracy generated by the Bill.

Your government has interpreted our commitment to our patients as support for the bill. It is not.

Yours

Dr Sam Everington

Chair, NHS Tower Hamlets Clinical Commissioning Group

c.c. Andrew Lansley, Secretary of State for Health


Email to MPs surname beginning with L: message/protest/warning from indignant GP in Tower Hamlets

12/02/2012

I am a hardworking GP in Tower Hamlets. My aim is to try to provide good quality primary care services to the local population of Bow.

I am indignant: you politicians and your colleagues at the Department of Health are designing policies which make my job harder, if not impossible. You dress it all up with words like ‘Choice’, ‘modernisation’, ‘reform’: but much of it is really just ‘sabotage’.

I am indignant: you are using a very stupid methodology. You avoid looking at risk; in fact, Andrew Lansley has gone so far as to keep risk secret. And you just seem to accept this. Is this intelligent?

I have been running a protest blog for the past year, and writing to MPs, one letter at a time. Now is the turn of the L’s. I know there is a convention that you don’t deal with issues raised by people who are not your constituents. (Do you read newspaper articles by people who are not your constituents?). Consider me a lobbyist then. I am lobbying on behalf of good quality English general practice. Am I paid to do this? No, it costs me. Do I stand to gain financially? I don’t think so.

I am doing this because I am indignant. This email, my blog, my activity on Twitter, is my protest, my tent pitched in the square.

My protest, my focus has been primarily on the issue of GP practice boundaries.

All 3 main political parties are in favour of the policy of abolishing GP practice boundaries, and allowing people to choose their GP practice without the constraints of geography, anywhere inEngland. When I first heard this proposal over 2 years ago, I could not believe that anyone would propose such a thing, so mad did it seem.

I will be brief, and if you want additional information, go to my blog. See links below.

1. You would think that anyone drawing up a proposal to change the structure of general practice inEnglandwould do some sort of robust assessment (including risks, unintended consequences, etc.) before launching the policy in public. This is basic, I think you would agree. Yet for this policy, there is no evidence that the Conservatives, Labour, or the Liberal Democrats ever did a risk assessment. I emailed Andrew Lansley in March 2010 and with some difficulty extracted the evidence that they had not carried out any risk assessment or feasibility study. New Labour and Andy Burnham’s evidence lies in the Department of Health’s documentation surrounding the so-called ‘Consultation’ Choosing Your GP Practice, launched in March 2010. This documentation lacks any serious examination of risks and unintended consequences. The documentation is essentially a PR exercise designed to elicit a ‘Yes’ to the questionnaire, which politicians have since used as ‘evidence’ that the people of England want to be able to choose a GP practice anywhere in England. Indeed, on more than one occasion, Andy Burnham has said, ‘I can see no reason why people cannot register with the GP of their choice.’ Not even one reason: clearly, Andy Burnham, despite being Secretary of State for Health, had not done a risk assessment. And he continues to say this sort of thing, as recently as December 2012. I have asked the Liberal Democrats (more than once) for any evidence that they carried out a risk assessment; silence.

This sloppiness, recklessness, arrogance: it makes me indignant, very indignant.

2. Your policy promises to give the people of England greater choice, ‘real choice’ as Andy Burnham has said. This choice is really an illusion. What you must understand is that the vast majority of GP practices are currently working at full capacity. They do not have spare capacity to absorb significant additional numbers of patients. Your idea is that the popular, well-performing practices that offer a good service will attract patients from the poorly-performing practices. This will simply not work, not to any significant degree.

Indeed, there is a risk that local people will not be able to register with a local practice because people outside the practice area have taken up part of the limited capacity. So far from doctors competing with each other, we will have patients competing with each other for places in a desirable practice.

And if you force practices to register all comers (as is currently the case with the 2004 GP contract), then the standards will fall.

Politicians and the Department of Health simply do not seem to understand the reality of capacity, and its relation to quality. This is very basic. It is shocking that an organisation that is supposed to organise a National Health Service should be so stupid.

Put another way, it is essentially a zero sum game. For some there may be some scope for expansion, but this will have its limits. Perhaps you can understand this if you think of the game of musical chairs. There are a limited number of chairs, more or less enough for the English population. Your modelling appears to assume the chairs are unlimited.

3. Then there is the reality of how general practice works: it is a local technology. The service works for a local community, and has links and networks to local services. We have worked in our community for 21 years. When people move away, they try to remain registered with us; our experience over the years is that this does not work, and is at times unsafe. I give examples of this on the blog.

To actually restructure things so as to remove the locality-base means to destabilise how the system works: it leads the system to malfunction.

You think you are doing something good when in fact you will cause a system under a fair amount of strain to malfunction: you are unwittingly sabotaging primary care. And you call this ‘modernisation’.

This too makes me indignant.

4. Let me return to capacity and quality, which is another focus of my protest on the blog. The current rules on patient registration is that we should register anyone in our practice area who wishes to register with us (=patient choice). But we found that this would destroy us; so we decided, unilaterally, to refuse to do this. We keep our list size at about 3,520; as people leave the area and the list, we register new patients. We have been quite open with the PCT and the LMC. The reasons are documented on the blog. I wrote to the Department of Health about this, and met with the then GP ‘tsar’. He agreed with me that this was not a sustainable situation, and said this was not a national policy but a local mistaken application of a national policy. I did not think this was the case. I asked who was responsible for this policy. He did not know. He did not offer to find out.

The recently published guidance to PCTs on the implementation of the pilot for commuter patients in 3 English cities (Tower Hamlets is included in the pilot) reiterates this directive: what we are currently doing is prohibited. We would have to either have to take all comers or shut the list to everyone (with the permission of the PCT). The guidance says that otherwise patients get confused. In our experience, patients understand this entirely and are not confused by it.

This is a very stupid policy and we will continue to adopt a stance of civil disobedience, and protest against it.

This too makes me indignant.

5. So if abolishing practice boundaries is so stupid a policy, why are they doing it?

There is a hidden agenda. What I believe this is really about is the deregulation of English general practice, the marketisation of general practice. Whilst the Department of Health goes on and on about patient choice, the true incentive is this: by eliminating practice boundaries, it will allow for profit organisations to set up primary care centres which can register people regardless of where they live. These centres will have no commitment to a community, to a locality. They will be based in city centres and their patients will be the healthy and mobile. If these patients get sick and are unwell at home, the centres will not have to look after them because they will not be local, they will be at home. Someone else will have to provide care for them where they live. (See the Department of Health guidance document, section 6).

Abolishing practice boundaries will ‘liberate’ the NHS for these entrepreneurial groups. These will essentially be glorified walk in centres catering for the healthy.

This too makes me indignant.

6. The proposed policy to abolish GP practice boundaries is a relatively small part of the Health Bill, and not on most people’s radar. But for general practice it is a very important issue.

The opposition to the Health Bill is growing inexorably. Even Tories are worried about the fall out. Andrew Lansley and David Cameron say they are determined to soldier on.

Let me give you a warning from the front line. Much of this Bill is built on PR: Choice, Modernisation, Reform of the NHS. Whenever Andrew Lansley or David Cameron or Simon Burns are questioned about an aspect of the Bill, these words will be central in their answers.

But what lies underneath all this? My wife is a member of the Tower Hamlets CCG. She is committed to trying to commission good services for the people of Tower Hamlets, but she thinks the structure that Andrew Lansley has designed makes the project unworkable.

I have studied the practice boundary issue carefully. It is a scam. My suspicion is that other aspects of the Bill are also scams.

If you push this Bill through, which seems to be the likely outcome as I write, things will unravel. They will unravel because built into their design are flaws. If this Bill was a building, it would not stand up, it would collapse. If it was a bridge, the bridge would collapse. So things will begin to malfunction, and it will be clear to all of us that they are malfunctioning because of design faults which are your responsibility.

At that point, the penny will drop. People will realise that they have been had, that all the rhetoric was just PR, emperor’s new clothes. And there will be anger; and this anger will be directed, rightly, at you. The warning signs are there: you can choose to pay heed, or you can plough on.

Reflect on this statement by Richard Feynman, the physicist, which I have adopted as the motto for my blog: ‘For a successful technology reality must take precedence over public relations, for nature cannot be fooled.’

*

Links:

1. My email exchange with Andrew Lansley

2. The problem of patient registration policy, in a nutshell

3. Your Choice of GP: the problem in a nutshell

4. The problem of caring for patients at a distance; examples

5. Email exchange with an MP attracted by the idea of being able to choose a GP at a distance

6. Email exchanged with The King’s Fund on GP practice boundaries

7. Department of Health Choice of GP Practice – Guidance for PCTs Jan 2012

8. Department of Health’s ‘Consultation’ PR exercise Your GP Your Choice Your Say


Thoughts on the GPC-DoH Agreement on GP Practice Boundary Issue

13/11/2011

News reached us just under 2 weeks ago the GPC and Department of Health had reached an agreement about the issue of practice boundaries. There are two provisions: 1. practices will be encouraged to reach an agreement with their PCTs about an ‘outer’ practice boundary which will allow patients to remain registered should they move outside the ‘inner’ practice boundary, ‘where clinically appropriate’. 2. There will be two or three city pilots for commuter patients to register with a participating practice close to their work, and an independent evaluation will be carried out.

I have campaigned on this issue, having seen the orignal proposed policy (patients in England being able to register with the GP practice of their choice, ‘anywhere in England’) as quite mad and unworkable. I am pleased with this outcome, and the GPC is to be commended for having negoiated this. As should the GP body that resisted the proposal.

This current arrangement implicitly recognises that general practice is a local and community-based technology, which the previous proposal (which all 3 major parties subscribed to) ignored entirely. Even the commuters will need to register with a practice not far from their work.

Of course, there are significant practicalities which will need to be addressed: who pays for the costs of the commuters? How is this money transferred? How does this fit in with Clinical Commissioning  Groups and commissioning? Certain areas, such as the Isle of Dogs in Tower Hamlets which hosts Canary Wharf and a commuter population of about 100,00, will be affected very significantly. And then, what happens when the commuter is ill at home, how does he or she access local help, especially if the illness needs more than one GP encounter?

It is absolutely vital that the ‘independent evaluation organised by the Department [of Health]’ be truly independent and honest and rigorous (that is, not on the model of the so-called ‘consultation’ on this issue carried out by the DoH in March-July 2010 which was PR exercise which misled the respondents and Parliament).

It must be said that the inner and outer boundary model is something that some practices have had in place for many years already. Under the agreed provision, practices will have the option of having an ‘outer boundary’ and clearly they will have to choose a boundary that allows them to deliver a functioning service. That is well and good.

It is very important that the politicians and DoH do not attempt to resurrect this mad idea in the future, and that we make it clear to everyone that UK general practice is at its core a locally based technology which simply does not work on the same model as McDonald’s and mobile telephones. It may be possible to make exceptions in certain circumstances (such as the commuter), but this is an exception rather than the thin edge of the wedge.

A large wooden stake needs to be driven firmly into the heart of this vampire. That is why I will continue to write to MPs and continue to write about this issue because I have not covered all the ground yet.


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]

*

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


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

*

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