13. How can they be so stupid? Corporate lobbying?


I put a question mark after corporate lobbying simply because I have no direct proof myself of this activity. I am close to certain that this activity has taken place over time with respect to the issue of GP practice boundaries, and I think it is likely that this plays a central role in driving this policy. The politicians talk about patient choice, but underneath it all is really an aim to de-regulate English general practice and open it up in quite a new way to for profit companies.

How and why?

At present practices cover a limited geographical area. This limits the number of patients. Remove this factor, make registration free of geography, then it opens up an entirely different model which can be exploited by companies like Virgin Care.

These companies can set up medical centres in major cities, wherever is most profitable. They will attract a clientele of mobile, essentially healthy professional people. They will not have to deal with these patients when they are actually sick because they will be too unwell to travel to their centres; someone else will have to visit them. The elderly, people with chronic diseases, will remain registered with local GPs.

It will be convenient for the mobile and well, and profitable for the firms. But it will not deliver primary care in any real sense, and will in essence be a virtual asset stripping.

10. How can they be so stupid? Wishful thinking….


If you are offered something attractive by someone, you naturally hope that it is what you are going to get. You hope it ‘will come true’, that it will not be illusory.

The property bubble and the disastrous crash in 2008 was at least in part built on ‘wishful thinking’. Bernie Madoff’s ponzi scheme went on as long as it did at least in part due to ‘wishful thinking’ on the part of his investors.

If Andrew Lansley is going to offer you choice, why turn him down?

‘I mean choice, at no cost, it can only be a good thing, right? We have the Department of Health’s assurance on this, right? I’ve read the leaflet, what’s not to love about it? Sure, I’ll go with choice, it’s a no brainer.’

8. How can they be so stupid? Duplicity


Duplicity:Oxford Dictionary of English: deceitfulness; archaic the state of being double.

Andrew Lansley gave a speech to the Royal College of General Practitioners’ annual conference in October 2011. I did not attend but fortunately the speech is available on video, as are the questions and answers after the speech. So I was able to listen to these. What he had to say about GP boundaries was actually not unreasonable, he seemed to have understood the problem (‘Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this.’; whatever was done had to work, they had to find ways that worked; ‘I’m not abolishing practice boundaries…’). But I was sceptical: let’s see what happens. A few weeks later the GPC signed a contract for 2012-13 which agreed to a pilot on GP practice boundaries, and for asking practices to create ‘outer practice boundaries’ which retained patients who moved from within the practice boundaries. This was not unreasonable, but I remained sceptical: how independent and probing would the ‘independent evaluation’ of the pilot be?

Then came the launch of the pilot, at the end of December 2011:

It allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

Health Secretary Andrew Lansley said:

‘Many patients are happy with their local GP practice, but a significant minority have problems registering with a practice of their choice. This pilot will mean patients taking part can access the high quality care they deserve in a place and at a time that suits them.

‘That’s why I believe patients should have the freedom to choose a GP practice that suits their lives, and not be restricted by geographical boundaries.’

He did not really believe what he said to the GPs in October. He was intelligent enough to know what sort of thing he had to say in order not to be eaten alive, but his intention was, and still is, to plough ahead with the abolition of practice boundaries. And this is how it was reported in the press.

In this sense, he is duplicitous, ‘double’, speaks with ‘a forked tongue’. Not to be trusted.

(For text of what he said to RCGP)

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.


The policy to abolish GP boundaries: a scandal in search of an audience


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

My email to MPs, surname beginning with H; copy to Health Select Committee



I am writing to all MPs, one letter at a time. Each letter is different. You are the H’s.

Quick summary: the proposal to abolish GP practice boundaries and give people more choice sounds good at first sight; but the practicalities mean that patients living at a distance from the practice receive poorer care; it is more resource consuming for the practice; and in some cases it is unsafe. Read on if interested; if not, press delete.

All three major political parties share the idea that abolishing GP practice boundaries is desirable. At some point in the future this will be exposed as a very stupid idea, especially when they try to implement it. Do you want to know why?

My wife and I have worked in a small practice in Tower Hamlets for 20 years. When we were interviewed to take this practice over when it became vacant in 1991, we were asked what we were going to do about the ‘outliers’ (people living outside the practice area). At that time, it was thought to be bad practice to have patients living at a distance from the surgery, and good practice to serve a community living close to the surgery. We have a relatively high turnover of patients and people move out of the area; and because we are popular, many of our patients try to continue using us as their GPs even after they have moved away. So we have had a lot of experience of trying to look after patients who live at a distance from the practice: we have acted in a way as a pilot site for this proposal.

And we can say that it is quite disastrous: patients don’t consult us appropriately: they leave things too late, or they don’t consult at all (and important things are neglected); or they save things up so they only make one trip and they then over-run their 10 minute appointment considerably; and then there is the problem of local services (which they are unable to engage with), and on and on. So to us this proposal is really quite mad.

In addition, it is unworkable because GPs are currently at full capacity; how are the popular GPs going to register more patients? And if they do, what about the local residents? For example, if 10% of the commuter population of 100,000 working inCanaryWharfdecide they want to register with a local GP, this will disrupt services for the current local population of 30,000 who are served by 4 GP practices.  They simply do not have the capacity to grow by 30%. And so on.

 ‘Choice’ has consequences, some intended, some not intended. There is no evidence that Andrew Lansley has thought this through; there is evidence that he has not thought this through: see my attempted email exchange with him from March 2010 http://bit.ly/f4iTA1

 See the Royal College of GPs’ response to the New Labour’s so-called consultation on this issue http://bit.ly/l3FrUA

 For a brief overview of the problem http://bit.ly/lo3hWq

For some examples of why this will undermine patient care http://bit.ly/l6fp0v & http://bit.ly/jhqdnw

I am aware that there is a convention that MPs only deal with issues raised by their own constituents, and their expenses.

 I am not writing to you as a constituent, but as a lobbyist. I am not paid by an American private healthcare multinational; I am lobbying as a citizen who happens to be a GP. Why am I doing this, at my expense in terms of time and petty costs? Because I valueUKprimary care and I do not wish to see you politicians flush it down the toilet bowl.

 To the politicians of integrity, I wish you well.



If you are a politician…


I appeal to politicians of whatever political party to look into the fine print of the ‘Choose Your GP Practice Anywhere in England’ policy. I know that this sounds like a good idea. Of course, who would refuse the opportunity of choosing whatever GP practice they wished in the whole of England? That can’t be a bad thing! Oh, yes it can…

For the difficulties created by the registration policy enshrined in current GP Contract 2004, click here. This will prime you to consider more clearly the implications of abolishing practice boundaries, and the problems of capacity.

For a brief outline of the problems inherent with Choosing Your GP Practice anywhere in England, click here.

For my email exchange with an MP, click here.

For my email exchange with ‘Andrew Lansley’, click here.

(Please feel free to comment, protest, challenge….)

If you are a journalist…


It must be said that these two related issues are not sexy. There are no naked breasts involved. But in a real sense they are scandalous.

The first problem, that of the current registration policy, involves a design feature in the 2004 GP Contract which, in our case, leads inexorably, predicably, to a decline in quality (and safety) of care, eventually to self destruction.

For a brief outline…

The second problem is the Government proposal to abolish GP practice boundaries. (In fact, all parties apparently favour this). This sounds like a good idea, who wouldn’t like to have the option of choosing whatever practice they would like in the whole of England, regardless of where they live? But would it work?

For a brief outline…


My email exchange with ‘Andrew Lansley’

My email exchange with The King’s Fund

My email to the Patients’ Association

If you are a patient and want to register with us…



You can register with us provided we have not reached our capacity. If we exceed this capacity then the quality and safety of our service is compromised. As patients move out of the area, our list size decreases and we are then able to take on new patients. Our GP Contract (which came into effect in 2004) requires us to register all comers who live in our practice area. We have struggled with this for several years but have reached the conclusion that this is a mad idea and a serious flaw in the design. So we are having to refuse to obey this requirement. We could apply to a panel to close our list but this would mean we would not be registering anybody and it has certain additional implications which I outline in the discussion on this blog. 

Can you register with us in the future if practice areas are abolished? The short answer is ‘No’. Why? This is a mad idea. We cannot look after all the local people who want to join our list. In addition, for a number of reasons looking after people at a distance will increase inefficiency, lead to poorer care, and in some cases be unsafe. See other posts for details.

For more information:    the problem with the current registration policy In a Nutshell

The problem with registering with a GP practice of your choice In a Nutshell

Why is the RCGP so supine?



Last spring the RCGP invited members to write in with their views to the Government’s so-called consultation ‘Your Choice of GP Practice’. The College said they were going to respond to the consultation and wanted to know our views. I sent my thoughts on April 5, a few days after the deadline. As this particular issue is dear to my heart, I awaited the College response. If there was a publication date, I missed it. Over the summer, I searched for it on the College site but could find no mention of it. On December 11, 2010 I emailed the College asking about it. No answer. I emailed again 1 week later and got an acknowledgement, saying they were passing it to the ‘policy team’. Then no answer. On 16/1/11 I emailed again. No answer. On 3/2/11 I emailed again, this time with a longer email, asking why I was having such a hard time getting an answer to a very simple question. I received a response the next day, giving me some links. One link was old and no longer functioning. The other link did not actually give me the document I was seeking but did take me to a page that, with some protracted searching, led me to the document I was seeking. So here, for those interested, is a link to the document.

 It is a good enough document and covers most of the areas I would have hoped and is pretty unequivocal: abolishing practice areas will create problems and undermine quality general practice. Let me quote paragraph 3:

Only a few of our members were positive about the proposals. An overwhelming percentage (approximately 75%) of our members who responded to this consultation were strongly against the proposals to allow people to register with any GP regardless of catchment area, because of their serious concerns about the potential impacts of this change for the health services provided for patients. Those members who recognised some merits in principal to the proposal also raised a number of serious concerns about the potential implications of the proposals. Our members often did not reply to the specific questions posed for patients in the back of the survey document: the questions were seen as ‘leading’ – implying a positive response to the basic proposal from the start, and thus not allowing respondents to express a strong negative opinion. It also in effect stops members of the public from expressing satisfaction with the status quo.

 In my response to the College in April 2010, I wrote:

Please, please produce a rigorous, strongly argued and fulsome response to this madness. Publish some sort of document and send it to every MP, and publish it online so the public can read it. The difficulty is that from the public’s point of view what’s not to like about this idea. It is just when the idea meets reality that the problems become evident.

The College reponse is good enough. By this I mean the document. The College response, in the wider sense of the word, is, in my view, almost non-existent. My suggestion that they send it to every MP and publish it online so the public can read it has certainly not been followed. Quite the contrary: I, a fee-paying member of the RCGP with a special interest in this issue, have struggled to get my hands on this document.

If you check the Home page of the RCGP today you will see all sorts of stuff about courses, conferences, revalidation, and so on. There is nothing about the Health and Social Care Bill. Why is there not a box somewhere on the home page, with links to other pages? If a politician were to try to do her or his job conscientiously and seek information from the RCGP website, they would find….nothing. What does the College think of the proposal to abolish practice areas? Do they have a view? It can’t be an important issue, so why are a few people making such a fuss?

Because the College is failing in this quite basic responsibility, I am laboriously emailing each MP with a link to this document. I am half way through the B’s.

One of the items that gets centre stage on the Home page is an appeal for funds for the new college site in Euston Square. I for one will not be giving anything for this. RCGP, if you are listening, I do not think you are doing your job. You are hibernating. If you put a an eye-catching link on the Home page to some useful stuff for journalists, politicians, DOH, and members of the public to see, then I will make a donation.