Dear Stephen Dorrell,
I sent a submission to the Health Select Committee in May 2013 raising concerns about the Government proposal to abolish GP practice boundaries (1).
A concluding paragraph read as follows:
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.
I sent an email to Jeremy Hunt on 8/9/13 raising my concerns (copied to you) (2); in response I received an evasive and irrelevant reply from the Department of Health (3); I sent a second email to Jeremy Hunt a week ago (again, copied to you) (4).
You were contacted by Pulse following my submission in May (5), and the article suggested that the Health Select Committee were going to investigate the policy. Has it done so? If yes, why was I not called to elaborate on, and to substantiate, my charges? If you have not investigated this matter, do you intend to and when? If you do not intend to examine it, why not?
I am aware that there is a glaring conflict of interest here, both for you personally and for your entire committee. Were you to investigate this policy, it would be very difficult to avoid coming to the conclusion that at best those involved in the planning and promotion of the policy were naive and ignorant and grotesquely incompetent (in short, a ‘blunder’); but, worst still, you might be unable to avoid concluding (as I have) that there has been a wilful misleading of the public and of parliament, that it is not just a blunder but actually a scam, a fraud. This would be embarrassing for your party as this, remarkably, appears to be a flagship policy for the Government (6), and embarrassing for the Labour Party (one of the prime promoters of this policy was Andy Burnham when he was Secretary of State for Health; he is now the shadow minister for health and his credibility would be severely damaged if a light were shone on his involvement). So I expect you will do all you can to avoid looking at this honestly and fully. And that in itself will raise further questions.
If your committee is unable to scrutinise this policy thoroughly, then who should?
The Tredegar Practice
35 St Stephens Road
London E3 5JD
16/11/13: Yesterday it was announced that GP practice boundaries would be abolished as part of the new GP Contract. I have not heard from Stephen Dorrell or any member of the Health Select Committee.
26/7/14: I never received a reply to this email which was copied to all members of the Health Select Committee
I wrote to you several months ago to check if you would be the appropriate body to deal with my concerns about a Government health policy. Two of your members kindly responded and said that it did seem appropriate for your committee. So I am now writing to ask you to look into the Government proposal to abolish GP practice boundaries.
The Government and Department of Health wish to abolish GP practice boundaries, saying that it will increase patient choice, drive up quality, and remove anachronistic constraints. From my perspective as a GP with 25 years’ experience of trying to provide good quality general practice to a local community, this policy may sound attractive on the surface, but in reality will simply not work and will cause general practice to malfunction; in some cases it will be unsafe. The Government and Department of Health are either remarkably stupid, or they have a hidden agenda and are engaged in an elaborate deception.
1. Who am I and why am I campaigning against this policy? I am a GP in Tower Hamlets. I have worked in our practice for 22 years. I was the medical director of the Tower Hamlets out of hours GP co-operative from 1997 to 2004.
I feel very fortunate and privileged to be working as a GP. Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.
As GPs we serve a local community. Over the years, in our practice, we have had lots of experience of looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney. We have found that these patients tend to delay being seen; that it is more difficult and time-consuming to manage their illnesses; sometimes they are too ill to travel to see us, and we are unable to visit them. At times it is unsafe. (Examples provided in links, see below).
So we are firm with patients about registering with a local GP.
When in 2009 politicians began to say that they wished to abolish practice boundaries, I was bewildered.
2. There are two main reasons why this proposal makes no sense: one, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; two, because GPs are all currently working at full capacity. The ‘good’ practices are already ‘full’ and cannot accommodate a significant increase in demand. There is a risk that ‘outliers’ will take the place of local residents, or impact negatively on the services of local residents.
So there is a very serious design fault at the heart of this policy. For the past 2 years I have been blogging, and writing to MPs, to Ministers, to journalists to draw attention to the problems inherent in this policy.
Last Autumn I wrote 6 articles for Pulse on this issue.
These articles are also published on a separate blog.
3. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But I now think that the evidence (evidence that is in the public domain) points towards a more disturbing process at work: that there is a hidden agenda behind this policy. My hypothesis is that the real aim here is to de-regulate general practice. At present, because it is geographically defined, it limits the type of business model that can be used to gain access to general practice. By removing the geographical element in primary care, you change significantly the business models and frameworks that can be applied.
But in order to abolish GP practice geographical boundaries, it has been necessary to create a pretext, or a series of pretexts. A narrative has been created and it has these elements: most people are happy with their GP; but some are not, and they should be able to have choice; GP practice boundaries constrain choice, they are old fashioned, anachronistic; there are a number of reasons why patients might want choice: to have a GP close to work, to register with a GP near their child’s school, to remain registered with their trusted GP should they move away; there might be a GP skilled in a disease in a practice outside their area; the only thing that is needed to make it all work is to sort out how visits will be done should the patient need one.
What this narrative leaves out are the two areas mentioned in (2) above: the systemic problems of patients living at a distance from their GP, and the problem of capacity. It also fails to mention the problems inherent in providing visits for people registered at a distance from their practice (see below).
4. Andy Burnham, then Secretary of State for Health, went to The King’s Fund in September 2009; in his speech he announced his Government’s intention to abolish GP boundaries within a year. He said this move would make a ‘good’ NHS ‘great’ (at least this is what the press reported; I have asked the DH to show me the press release for this occasion; thus far they have been unable to produce this). But what he said about this in his speech really amounted to nothing, it was meaningless to anyone who understands how general practice works (and does not work).
5. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice, launched in March 2010. If you look at this ‘consultation’ with a critical eye it is clear that it steered the readers towards responding in certain ways to the questionnaire. It used the narrative outlined in (3).
When it published the results of the consultation, the DH claimed it showed that the public backed the idea of choosing your GP practice and doing away with practice boundaries. Of course it showed that, it was designed to show that. Had they been honest about the reality of general practice, the respondents would have said: given what you have told us, why are you even proposing this policy?
6. The DH agreed with the GPC to hold a pilot around this policy. The pilot is in progress. The present Government went so far as to say, in their Mid-Term Review, that this pilot was evidence that the Government had improved the NHS. “We have improved the NHS by …..—allowing patients in six trial primary care trusts to register with a GP practice of their choice.” What the report omitted to say was that GPs in two of the six PCT areas opted to boycott the pilot because of concerns of the impact on resources of the local health economy (one of the many problems inherent in this policy). What they also failed to say was that of a possible 345 practices in the pilot areas, only 42 practices had opted into the pilot, and that as of the beginning of the 2013, only 514 patients had registered with a practice under the scheme.
This ‘pilot’ in no true way tests the policy. The Government and DH say that there will be an independent evaluation of the pilot. Given their behaviour so far, my concern is that the ‘evaluation’ will somehow avoid scrutinising the policy, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.
7. The problem of visiting. People on all sides of the debate have acknowledged that the issue of visits would need to be addressed. But what most people have failed to grasp is the magnitude and breadth of this issue. At present, all patients are visited by their own GPs within working hours (8am to 6pm [or is it 6:30?]), Monday to Friday. And if the call is outside these hours, then there is a local arrangement for how these visits are covered. There have been problems with out of hours provision, with some high profile cases where patients have died due to not being assessed properly.
If this policy is enacted, then every area in England will require a structure to provide care for those who live at a distance from their registered GP. This provision will have to cover not only the out of hours time slots, but will of necessity be 24 hours a day, 7 days a week.
It is also important to understand that when a patient is seen out of hours, the notes from the encounter are sent to the registered GP. Almost always the notes contain a message that says something like this: ‘If not improving, for review by own GP.’ The trouble with the boundary free model is that there will be no local GP to manage the patient while unwell during working hours and at home. The out of hours service does not provide continuity of care, and does not arrange further investigation and referral where this is warranted.
8. I think there is a case for finding a way to make good quality primary care accessible to people who work long hours at some distance from their homes. But the people designing a solution would have to adopt a sound methodology which would include honesty, common sense, and truly taking into account the ecology and practicalities of general practice.
9. 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.
10. I am writing as what some might call a ‘whistleblower’. That a busy GP should have to spend all this time in trying to get this message through to the politicians seems to me absurd. I am writing in the hope that you will listen and scrutinise this policy. But I am aware that there are many reasons why you as a committee might wish avoid this.
I am also writing so at least at a future date, when the inevitable problems surface, that you will not be able to say ‘Nobody warned us.’
The Tredegar Practice 35 St Stephens Road London E3 5JD
(Numbering corresponds to the paragraph numbering above)
2.. Looking after patients at a distance from the practice does not work and it at times dangerous:
3. a. The narrative: the mainstream press has so far largely just reproduced what the Department of Health Mediacentre have told them in the form of press releases. There have been three main press releases, and corresponding articles in various media. Analysis of these articles shows that mainstream journalists for the most part do not understand how general practice works, and that they have uncritically taken the DH formulations and promises as fact, when in fact they often do not make sense.
In time, the mainstream press may well wake up and look into this issue.
b. The problem of capacity:
In our practice we have struggled with this. Because we are popular, people have wanted to register with us. This has driven us to a list size beyond our capacity which has a negative impact on the quality of the service we provide for our patients, and we have a workload which is unsustainable. The only way we have had to cope with this is to shrink our practice area further a few months ago. So there is no way we could cope with an influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised), we are drowning as it is.
I came across an example which illustrates this problem recently. There is a practice in Kentish Town with a long established reputation; just the sort of practice that people for several miles around might want to join (if I did not know better, I would consider joining as they are less than 2 miles from where I live). If you go to their practice website you will see the issues they are wrestling with as raised by their patient representation group.
They are having trouble providing access to their currently registered patients, all of whom reside within their practice boundary.
Another example which illustrates this in a farcical way. The DH chose City and Hackney as one of their pilot sites. The City is served by one practice, which has a list size of under 10,000. As it happens, the City of London Corporation and NHS Northeast London had commissioned a study into the practicalities of providing primary care services to the commuter population of the City. The conclusion was that something like 120,000 of the 360,000 commuters were likely to want to register with a GP practice in the City, which would require 50 more GPs, and additional practice nurses and infrastructure. So there was really no way that the sole City practice was going to be able to cater to commuters interested in taking part in the pilot.
4. On Burnham visit to King’s Fund, see my post.
5. On Government ‘consultation’, see my post.
6. On the Choice of GP pilot, see my post.
I emailed members of the Parliamentary Health Select Committee earlier in the week. I have received a reply from two of the members, Sarah Wollaston (herself a GP), and Barbara Keeley. Here are their replies:
Dear Dr Farrelly,
This does look like the kind of issue that the HSC could look at but we have many outstanding and potential enquiries and the whole committee vote to decide on the order in which they are examined. I’d be happy to see this added to the list as part of the wider review of GP services and the important issue I’ve already raised of understaffing. I agree this issue of boundaries is very important.
Dear Dr Farrelly,
Thank you for this, it is very worrying.
As far as I understand it, the brief of the Health Select Committee is to hold the Department of Health to account:
“The Health Committee is appointed by the House of Commons to examine the policy, administration and expenditure, of the Department of Health and its associated bodies.” (quote from Committee’s page on the website)
So the matter you raise would fall within the Committee’s remit.
Barbara Keeley MP
Dear Health Select Committee Members,
Brief Summary: I am a GP; there are very significant problems with the policy of abolishing GP practice boundaries. Is this a matter for you; if not, why not, and who should concerns be addressed to? Is this an example of grotesque stupidity or deception? I am writing a series of articles for Pulse on this issue.
I have been a GP in Tower Hamlets for over 20 years. I was the Medical Director of the Tower Hamlets GP out of hours co-op from 1997 until 2004 when the PCT took over responsibility for out of hours cover. I know a fair amount about the practicalities of providing good quality general practice to local population.
Because we are a popular practice, when patients move away they often want to remain registered with us. This has given us, over the years, a lot of experience in looking after patients at a distance from the practice. And it is clear that it does not work: the greater the distance from the practice, the greater the barrier to care; it is inefficient, time consuming, and at times unsafe. That is why we insist that these patients register with a local GP. Here is an example of the problems that arise.
This is just the tip of a very large iceberg. There are numerous other reasons why this does not work.
So it is very bewildering to us that politicians and (anonymous) policy makers at the DH should be backing this policy. I used to think it was just grotesque stupidity that drove this. But this just does not make sense, it does not add up. A more credible explanation is that there is a hidden agenda: the drive to abolish GP practice boundaries is not about giving patients choice (which it will not in fact do), but about freeing up (‘liberating’ to use Andrew Lansley’s language) English general practice to a different structure which will please Virgin Care and McKinsey but will actually destabilise and undermine good quality general practice, and introduce additional costs.
So either politicians and the DH are remarkably stupid (in which case they should not be in charge of this), or they are carrying out a deception on the English public (which is really quite shocking).
I am writing a series of articles for Pulse, a GP publication. As part of my research I want to find out what the Health Select Committee’s brief is. If what I am claiming has a solid basis (and I have evidence to support my claims), would this be in your remit? If it is not, why not? If it is not your remit, then who should GPs, and patients, address themselves if they find themselves sharing my misgivings?
BA, MSc, MBBS, MRCGP
The Tredegar Practice
35 St Stephens Road
London E3 5JD
“For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.” Richard Feynman, Physicist
cc to Health Editors at Guardian, Telegraph; Mirror; Daily Mail; Jennifer Dixon, Nuffield Trust; Clare Gerada, RCGP Chair