My email to NHS Medical Director at Department of Health May 2010

30/01/2011

 

Dear

I am a GP in Tower Hamlets. Several weeks ago I received the booklet The NHS Quality, Innovation, Productivity and Prevention Challenge: an introduction for clinicians. I felt I needed to respond to this, and I sought your email address which you kindly provided.

I had mixed feelings on reading the booklet: on the one hand, relief that someone at the DOH wanted to look at the issue of quality, on the other hand anger because for some years we have been the victims of government and DOH-led initiatives which have had a direct effect of lowering quality. It may be that you and your colleagues are truly interested in quality, I hope so. But you need to know that it is likely that down the corridor from you (metaphorically speaking) there are others planning policies which will impact negatively.

There are numerous examples of the madness which is visited upon us. I will give you one. In brief it is this: the 2004 GP contract stipulates that we cannot cap our list size; we are required to register any patient living in our practice area. We can apply to close our lists; this requires approval by a panel; once closed, the PCT can withold enhanced services payments (because a practice with a closed list is in essence a ‘failing’ practice and therefore not fit to be providing enhanced services). We are advised that to apply to close our list is a last resort.

We are a small practice. We aim to provide good quality primary care. We have been in the practice for 19 years. Our patients value what we provide. They do not want us to expand beyond recognition, they do not want us to implode. A year ago we put our foot down: we would not go beyond 3,520 patients. We were upfront with the PCT. They advised us to reduce our practice area (this was the only mechanism by which we could ‘legally’ achieve our aim). But how do you adjust your practice area so that you can achieve a steady state of 3,520? I attach 3 documents which chart this particular issue: the email exchange I had with the LMC, and then PCT; the Tower Hamlets registration policy 4.09; a document I drafted in response to this registration policy. If you read these documents you will note that quality is an important ingredient which requires attention. (Incidentally, we do well in the MORI survey, we are considered one of the model practices in Tower Hamlets, so what I am writing is not sour grapes).

In November 2009 I was invited to a meeting at the PCT. I outlined the double bind that this policy puts us in; I told them it was bonkers; I acknowledged that they were caught in the middle, that their careers required that they implement what people at the top deem to be policy, that there does not seem to be a mechanism for feedback in all this (and you will know that feedback is a vital part of functioning systems). I told the PCT that I was not willing to die implementing a bonkers policy (I work a 60-70 hour week and I am techinically a part time GP). I said if they forced us to increase our list size that I would resign, but not before our patients became aware of the issues at hand and were able to communicate their feelings to the PCT and the press. The PCT had no response. They were shocked. We continue to be in breach of our contract. I happened to meet Andy Burnham when he came to Tower Hamlets recently: I told him we were in breach, that we were being asked to do something mad and that we had finally woken up and decided to resist. His expression was blank; he really does not understand what actually happens out here.

I could go on and on, there are other areas where stupidity (not quality) reigns. (The current, presumably to be shelved, ‘consultation’ on choosing your general pracgtice is another example of this). My message to you and your colleagues is don’t send me leaflets with rhetoric about quality if you are asking us to do things which undermine quality. The problem is not with one or two isolated areas. Shot through the policy making and implementation framework are weaknesses and flaws which inevitably lead to dysfunction. It is very demoralising. What keeps me going is that I value the work we do and the patients value it. I feel fortunate to be doing this work. But I am really fed up with the rhetoric and arrogance and ignorance of the politicians and faceless people at the DOH. I will continue to resist.

I do hope you and your colleagues are truly in pursuit of quality (and not just saving money); if so, I wish you well and would support your effort.

Best wishes,

George


My email to PCT

30/01/2011

 

Dear A,

 You will see that K suggested I forward the attached paper to you. I have since added a few notes to the document and what you have is the amended version with additions. I attach the PCT registration document which outlines the policy.

 From my point of view this registration policy is inevitably, for some, a double bind: if you follow it you will self-destruct. (It is fine for those practices seeking to grow, for whom growth makes sense). I am told that this is government policy, that this comes from on high at the DOH. So you at the PCT are just following orders.

 Would you be able to tell me who at the DOH has responsibility for this? What department deals with this? Which minister deals with this? Is there a review body within the DOH which evaluates or reviews policy?

 I must say that I had not been aware of this notion of ‘churn’, that some people think it is a good idea to increase turnover, increase patient movement between practices. This might be useful in some contexts, but to wish to encourage it generally is perplexing to me. Does the Tower Hamlets PCT think ‘churn’ is a good thing?

 Do you have any ideas how, within the current context, a small practice like ours that aims at quality and whose patients wish it to remain the way it is, survives? (We will be discussing this issue at the next patient participation group meeting). Who at the PCT should patients address their concerns to?

 Best wishes,

 George


Our patient registration dilemma: chronology

30/01/2011

 

2004   Introduction of new GP contract. A number of aspects very welcome. One problem is that we cannot limit our practice list size. We must register anyone who wants to join, provided they live in our practice area.

We struggle with this. Our list size grows inexorably. Working hours expand. I go to work at weekends to catch up, try to stay on top of things.

2007 (?)   The PCT calls an emergency meeting. Tower Hamlets has performed poorly in a national poll on patient access. The poorest performers are categorised ‘Red’, the next ‘Amber’, those doing well ‘Green’. Our practice is one of the six green practices.

I go to the meeting and say this: ‘I shouldn’t be here as we’re green, we’re not a problem. But we have a really big problem. This business of having to take all comers, you might as well come and drop a hand grenade into our practice…’

They have other fish to fry that day.

2008   We agree with the PCT to increase our list size by 400 (up to 3,516 patients). The PCT gives us some money up front to do this. We undertake building works to create an additional consulting room.

The building work is stressful. The cost exceeds our grant. The list size grows. The workload grows. We take on addional administrative and nursing staff.

 2009    April. We near our agreed list size of 3,516. So what happens now? I cannot go on like this. We receive the PCT Patient Registration document reminding us of our contractual obligation to register anyone.

I decide to name the new consulting room The Bateson Room after Gregory Bateson (see Wikipedia), because of his work on the functioning of systems, the importance of being systemic.

May. I make some notes on the back of an envelope. I write my 4 page document. I am beginning to wake up to the fact that this requirement is not only a pain in the bum but actually a systemic flaw that, if followed, actually leads to malfunctioning and destruction of the system. I send the document to the Local Medical Committee.

I remember that Gergory Bateson also came up with the double-bind theory of schizophrenia.

I decide we will not grow larger than 3,520. I will resign if forced to do so. Nobody in the practice says we should grow though there is some disquiet that we should ‘break the rules’.

Response from LMC.

I send my document to PCT. One question I ask: “I am told that this is government policy, that this comes from on high at the DOH. So you at the PCT are just following orders. Would you be able to tell me who at the DOH has responsibility for this? What department deals with this? Which minister deals with this? Is there a review body within the DOH which evaluates or reviews policy?” I received no answer to these questions.

We continue to register patients when we have capacity.

November. I am invited to a meeting at the PCT, for the PCT to hear from practices. Practice managers, GPs, the PCT medical director. The PCT managers are there to ‘listen’. When it is my turn to feedback, I say this (abbreviated format): “I went into general practice to do a good job, to offer a quality service. This policy of having to register all comers makes this impossible. It is a f**king bonkers policy. I know you can’t tell the people further up the planning chain this because your careers would not be helped. You have rubbed our faces in the sh*t since 2004. I refuse to grow any further; I refuse to die for your f. bonkers policy. I will resign if you try to force us on this, but before I go I will explain to our patients and they will tell you what they think.” After the meeting, the medical director says to me: the managers are in shock.

We continue to register patients when we have capacity.

2010   

May. I receive an NHS booklet on achieving good quality care. I spend time tracking down the email address of one of the authors and send him an email: it is all very well to urge us to aim for quality care, but you have to make sure there are not policies that undermine this. He forwards my email to the National Director for Primary Care at the DOH.

July. I meet D., the National Director for Primary Care, a retired GP. I outline the difficulty posed by this requirement to register all comers. He agrees that this is an unsustainable situation; but he says this is a local misinterpretation of national policy. He offers to speak to A. at Tower Hamlets PCT. I say that we have sorted our problem, we are just refusing to obey this directive. But I am concerned that others are having to work with this policy. I say my impression is that this is a national policy. I ask who is responsible for this, who should I speak to at the DOH. D. does not know. He does not offer to find out and try to sort this problem out. I mention my concerns about the proposed policy to register with a GP anywhere in England. He says it would suit him as he spends a lot of time in London.

July/August   I carry out an email correspondence with the BMA (General Practitioners Committee). They say that our registration dilemma is a national issue; they sympathise with our quandry, but advise that the only thing we can do is shrink our practice area, or close our list. They advise that we keep quiet about what we are doing.

We continue to register patients when we have capacity, aiming to maintain a list size as close to 3,520 as possible. We do not select whom we register.


Email from LMC in response to my document on registration, 12/5/09

30/01/2011

 

George

This is a very thoughtful paper, and I am sure we would all agree with the main thrust of your argument.  You might want to send it to [the PCT]… also.

Negotiations are always a compromise, and what we had to be aware of when we had to negotiate at LMC level to produce this document was a recognition that the old “open but really closed” option was unsustainable.  The second thing we had to recognise that the contract specifies we cannot discriminate against patients so if a list is open we have to register everyone, including those from neighbouring practices. Now it is true the government, who believe in choice and competition, would like a 30% churn of patients every year between practices.  But patients don’t want this, so I don’t believe that there will be massive flows from one practice to another. If there are, then this might raise clinical governance issues about the practice the patients are all leaving, that the PCT or the LMC may have a duty to intervene in.

Far more of a threat to us all, but perhaps especially to your practice is the rising Tower Hamlets population. Here there is a dilemma. Either the existing practices soak all that up and expand capacity, or we ask the PCT to procure more practices and they will only be allowed to do this by an APMS procurement route that opens the door to more privatisation.  Each practice has to make its mind up about this. You could close your list, or attempt to reduce your practice area. If you closed your list, the PCT would feel they could refuse to give you enhanced services.  If you wanted to shrink down your practice area, then you would undoubtedly get LMC support I think, if the PCT refused this.

 Best wishes


My Document on Patient Registration May 2009

29/01/2011

 

[I sent the following paper to the Tower Hamlets LMC (Local Medical Committee). It gives the context and needs to be read together with the Tower Hamlets PCT document on patient registration, see link at end of page]

*

The problem of patient registration in Tower Hamlets: one GP’s view (George Farrelly, The Tredegar Practice), 6 May 2009

I am writing to raise concerns specifically about the issue of patient registration, and I will perhaps mention wider concerns as well.

We were recently sent a document entitled ‘Guidelines for registering with a practice in Tower Hamlets’. My understanding is that this document was drafted jointly by the PCT and LMC.

It raises again an issue which has been present for many years and has not, to my mind, really been addressed. That issue is how can the PCT plan General Practice capacity so that it deal effectively with the population of Tower Hamlets.

I will speak about our practice and our personal experience. The specific issue is registering patients, adding patients to the list. (The PCT document also alludes to providing emergency, and immediate and necessary treatment, and this is another issue which I will not address directly now).

*

In about 2002 or so the ideas for the new GP contract were in the air. The idea which appealed to Isabel (Hodkinson) and me was that our job description would be more clearly defined, that we would be paid for work we were already doing but was unpaid (in essence the sort of work we undertook under the ‘Healthy Eastenders’ project which then became the Clinical Effectiveness Group). In essence, an updated, modern GP contract which would pay for a quality service. We welcomed this idea. My thought was: Great, we can look after a smaller population but actually do it well.

(We are not in it for the money: our prime aim is to offer a ‘gold standard service’, of which all practice staff can be proud. We obviously have to pay the mortgage and cover expenses, but we do not aspire to expensive cars and second homes).

When the new contract actually arrived (by way of the Carr Hill formula madness which occurred at the same time as the invasion of Iraq: a very good time to bury bad news), it included a stipulation that we could not close our lists. Now this is not a problem for a practice which is aiming to increase its list size but is a problem for a practice which feels it is at its correct size (see below). People high up in the planning chain were keen to promote the ease of changing practices so that patients could leave practices they were not happy with and join the ‘good’ practices in their locality. But inherent in this model is a basic flaw: if demand exceeds capacity, then if this model is adhered to then the ‘good’ practices will implode. Why? Because in this ‘free market’ model patients will move to the more desirable practice; because as capacity is exceeded, the quality of this ‘good’ practice will fall and its performance will decline. Gradually, if the system truly works as a free market, the ‘good’ practice’s quality will reach a stage when it matches the quality of the ‘undesirable’ practice; then flow between the two will cease. Of course, if capacity exceeds demand  then the planner’s dream will be realised: practices will compete with each other and thereby raised their standards. But in the real world of Tower Hamlets that situation simply does not pertain.

In my conversations with other GPs in the last few years, I have never heard of a practice (unless they actually wanted to grow and were actively seeking patients) who did not in some way limit the number of patients they took on. Yes, we were registering patients, but not in the manner that the ‘free market planners’ would have wanted us to. Because had we done so, practices would have self-destructed. And so, sensibly and wisely under the circumstances, so as not to self-destruct, practices rationed registrations in whatever way they had to.

*

The plannners should be asked: imagine your favourite restaurant. You like it because of its ambiance, the good service, the excellent food. Other people like it, which is understandable, so you have to book in advance. You have to book because there is a limit to how many diners they serve, this you can understand. But now imagine this: the Minister for Dining Out wants to make good restaurants accessible to all and a decree goes out: you cannot limit the number of diners at your restaurant, you have a responsibility to seat anyone who wishes to eat at your restaurant. Now you don’t have to book, you just go. You can imagine the scene: they have crowded in more tables, there is a pressure to eat quickly because disgruntled people are milling around on the pavement impatiently; the quality of the food has dropped; the owner is stressed and irritable. Where has your favourite restaurant gone?

*

The basic reality of our practice is that we have a limit to how many patients we can look after well. If we exceed this limit, then the system becomes stressed; if the system is stressed it functions poorly and those within the system (patients, staff) are less satisfied. There then comes a time when the system becomes unhealthy: unhealthy for patients, unhealthy for staff.

The planners behave (in their communications, in their planning, in their priorities) as though they do not understand this.

*

The document on patient registration (see link below) is concerned solely with registration.

I think it is essential to broaden the picture and to look at other areas as well: Access (which will obviously include registration but also the access that already registered patients have); Quality (the quality of the overall service for the patients; the quality of working conditions for the staff [support, training, development]; the quality of the structures of the practice [IT, for example]; ‘Organisational Development’ would fit into this area; quality of communication: between practice and patients, between staff within practice; etc); Capacity (what is the point beyond which Quality and Access decline?); and Resources (what are the resources available to the practice: staffing, financial, etc?).

Access Quality Capacity Resources

Once vital thing to remember is that these areas inter-relate (hence the arrows). If one area changes, it will have an effect on the other areas, or for change to occur in one area you will have to make changes in another area. Access will depend on capacity; capacity will depend on resources; resources can be enhanced if the quality of planning is good; to have high quality planning within the practice requires time and resourcing; and so on. It is a system, it interacts. We should see it as an ecology; we should think ecologically about it.

I do not think the planners have this perspective. We need to ask them to adopt this perspective, otherwise the system will suffer: we will all suffer. In fact, we are all currently suffering and we need to try to reverse this.

*

About a year ago, we agreed with the PCT to increase our list size by 400 patients, taking our list to 3,516. We were given some money to do this. We have undertaken building works to create an extra consulting room. This development has cost us: the actual building costs has exceeded the money advanced to us by the PCT; it has required a significant amount of time by staff (uncosted, not resourced); it has caused a considerable amount of disruption. We have increased our staffing, which we are funding. Our impression is that our (IH and GF) income will fall.

Our working hours have expanded: at least one of us (sometimes both) stays later than 9pm in the evenings to deal with basic administration (results, post, repeat prescriptions, reports, phoning patients); I go in at weekends (one or two days each weekend; the Easter weekend I went in on 2 days; the early May Bank Holiday 2 days, notwithstanding the fact that we are officially on leave this week, and so on). I have reached my limit. There are no more hours in the day, no more days in the week; I must sleep, I must go home, I must rest.

We have reached capacity (really, we are exceeding capacity…). So we cannot grow. We are a small practice and choose to remain that way; our patients like the way we are, and do not want us to increase the list size: access falls, the friendly small practice ethos is undermined.

So how do we deal with this requirement to register all patients who present themselves? The only way we can see forward in this slightly mad situation is to shrink our practice area boundaries. We will have to adjust the boundaries so that we reach an equilibrium: find a practice area size which allows a balance so that our list size remains a constant 3,520, give or take a few. It will probably require that we periodically re-adjust the area (widening, shrinking) from time to time.

*

It seems to me that the PCT needs to assess the demographics in the various areas of Tower Hamlets. For example, what is the projected growth in population in Bow? Will the current capacity (local GP practices) be able to register these patients? (To determine this the PCT will have to have a dialogue with practices). It is simply not possible to just say to practices: you must register them all, it is your responsibility. Which in essence seems to be the current stance.

*

These notes are meant to be the beginnings of a conversation. A conversation between us and the PCT; us and GP colleagues; us and our patients. There are wider issues such as the ‘Resourcing General Practice’ project which need to be discussed as well but I have restricted these notes to the issue of patient registration.

George Farrelly

The Tredegar Practice

6.5.09

(written while ‘on holiday’ because there was no time to do so when ‘at work’)

* * *

23.5.09: The following are a few more notes added to the above document in order to give some simple, concrete examples of the way growing the list size has impacted and continues to impact on quality. I have been advised to forward this document to the PCT and so add this to illustrate the problem.

Our baby clinic: IH has always led on our baby clinic. Originally this ran every Tuesday afternoon and was staffed by IH, our practice nurse, a health visitor and an auxillary, and one of our receptionists. At the end of each baby clinic there is (was) a meeting between the professionals to share information and concerns about given children/families.

A few years ago, there was a centrally decided reduction in health visitor time (resource) so that the baby clinics were cut from weekly to the 1st, 2nd, (and 3rd when there was one) Tuesday of the month. This of course reduced access, reduced capacity, and reduced quality (the baby clinics were busier, there was less time to listen to concerns). The immunisation schedules in the meantime increased, which put further demands on capacity.

Now add to this an increase in list size: we have had a 50% increase in births due to the demographic changes in our list (a higher proportion of people joining the list are young due to housing changes locally). So we are fitting the increased workload into the same (reduced) baby clinic resource. Baby clinics are hectic: the waiting room area is overcrowded, the waits longer, the time taken to talk reduced; IH does not feel she can spend time with parents discussing their concerns; the clinic frequently overruns so that there is less time for the post-clinic meeting.

So this is an example where access, quality, resource, and capacity are negatively affected by an increase in list size without thought being paid to these other areas. But, of course, it has a wider impact than this: if parents cannot get their concerns addressed in the baby clinic, then they have to book a slot in normal surgery time. Then add to the mix that the PCT has essentially seconded IH (reduction in resource) to work on the wider diabetes project and she is therefore less available: parents therefore are more likely to see a GP who is not as skilled in dealing with baby clinic issues and concerns…..

*

An increase in patient registration (access from the point of view of unregistered patients, call this Access 1) will (if not accompanied by an increase in capacity) lead to a reduction in access for those already registered, call this Access 2. (I have had that complaint from patients: they have reported that the access has worsened: but of course it has, think of the restaurant example).

With the increase of our list size by 400 over the past year, inevitably our overall access is poorer. Will this be reflected in the access MORI poll? Will we who were once green turn amber or even red? Oh, those slackers at the Tredegar Practice!

* * *

Going back to the patient registration document. In essence what this document is asking us to do is to offer 48 hour access[1] not only to our currently registered patients (which is in itself a considerable challenge) but to all people in our practice area, even those who are not registered. The document asks that we register these people when they first present and be in a position to offer them an appointment within 48 hours. Without a very significant increase in resourcing (to allow an increase in capacity…) this cannot be done. And in a system where the total population (registered and unregistered) currently exceeds capacity (and the projections are for population growth), then to follow the patient registration document to the letter would be self-destructive, a march of lemmings.

5.7.09: A further added note which is quite relevant but only given a brief mention above. In fact, it should be added to the Access, Quality, Capacity, Resources ecogram. This is the question the Safety. There comes a point where when capacity is exceeded and the strains on the system are such that mistakes are more likely. Some of these mistakes may be benign, but some mistakes may have potentially serious effects.

I have noticed in the past few months a quite noticeable increase in mistakes (in prescribing; delays in referrals, labelling abnormal results as normal) which were previously rare.

This adds another reason to resist the pressure to grow the list beyond a practice’s capacity.


[1] The 48 hour access target is something that would merit some discussion but it is not discussed. My understanding is that it was the brainchild of Mr Tony Blair: evidence-free policy making which then ended up being a planning priority and leading to choices which impact quite significantly on the health economy as a whole. The PCT’s Access LES quotes the ‘Ipsos-MORI patient survey’ in much the same way as other LES’s quote QOF which at least is evidence-based. It is really quite shocking and shameful, much more significant, I believe, than the issue of MPs’ expenses. But this is another issue and I must restrain from letting it intrude here.

Guidelines for registering with a practice in Tower Hamlets PCT 4.09