4. How can they be so stupid? Naivety


We are all naive about some things, inevitably. If we are wise, we know when we are naive, when we are stupid we are unaware of our naivety and act as if we understand a situation. A recent experience of mine: my wife and I have been to the US on a holiday. We spent some time in different cities (Seattle, Vancouver, San Francisco, Brooklyn/NYC); now each city’s public transport city operated in a slightly different way. Tickets, free areas in some cases, how to pay, etc: we had to inform ourselves and understand the system if we were to minimise the cost and get to where we wanted to get. On arrival in each city, we were ‘naive’, inexperienced. Had we assumed the system would operate the same way as London Transport, we would have been ‘stupid’.

Oxford Dictionary of English: naive: adjective, showing a lack of experience, wisdom, or judgement: the rather naive young man had been totally misled.

A patient of mine who had moved to Clapham and could not see why he needed a local GP: he was unaware that GPs visit their patients if they are too unwell to get to the surgery. In this sense, I would say he was naive, he simply was unaware of how the system works. He was sensible enough to see that there was no way that I would trek across London to visit his sick bed.

the rather naive young man had been totally misled: this sentence brings up the other side of the coin. People can be naive through lack of experience, but this lack of experience can be taken advantage of by others. In this case, I think it is clear that the Department of Health are misleading people and taking advantage of their naivety. I will offer some concrete examples later.

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


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

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


Ignorance (wilful and unwilful)

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

Misinformation (wilful and unwilful)



Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)

2. Why pursue this issue of practice boundaries?


Why have I doggedly pursued this issue?

Because not only is it remarkably stupid and simply will not work, but it will also cause the current system, with all its complexity and problems, to malfunction.

Looking after patients at a distance creates all sorts of problems (it is inefficient, more resource consuming, at times unsafe), if people from outside an area register with a practice they will almost inevitably displace a local resident from registering with that practice, or at the very least take some of the resources away from the local population.

So it seems to me essential that we put a stop to this madness. And because in December 2010 nobody else seemed to giving this issue any attention, I decided I must so created this blog and started writing to MPs.


1. This really has to stop


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.