Department of Health response to my email to Jeremy Hunt: the smell of rotting fish

21/09/2013

Yesterday I received the following email from the Department of Health. It alleges to be a reply to my email of 8/9/13 to Jeremy Hunt. It does not address any of the concerns I raised in that email. It is quite random, though it does contain some worrying messages, no doubt unintentionally.

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Dear Dr Farrelly,

Thank you for your correspondence of 8 September about the pilot scheme to remove GP boundaries in six primary care trust (PCT) areas.  I have been asked to reply.

The purpose of the piloting arrangements was to trial the scheme with a limited number of practices in a limited number of PCT areas, the aim being to test whether these arrangements still provided patients with the best possible primary medical services.

Where a patient chose to register with a GP away from the area in which they lived, any urgent or immediate care was be the responsibility of the PCT for the area where the patient lived.  When registering, it was made clear to patients that they may be contacted to discuss their experience of being registered with a GP practice under these arrangements for the purposes of evaluating the arrangements.  Participating practices and PCTs were also interviewed.  An evaluation report has now been received by NHS England and is receiving consideration.  Following that consideration, a decision will be taken on whether to extend the arrangements across England.

I hope this reply is helpful.

Yours sincerely,

Patrick Driscoll
Ministerial Correspondence and Public Enquiries
Department of Health

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I will be sending another email to Jeremy Hunt. In the meantime, it is worth noting that the DH official says that an evaluation has been carried out and the results sent to NHS England and is receiving consideration. Now this is surprising because the DH announced a year ago that the pilot would be extended by six months due to the chaotic first six months of the pilot. This would have meant that the pilot would have ended now, in September 2013. At this point, now in September, the evaluation could have been carried out. Instead we are told it has already been carried out. I smell the stink of rotting fish.

Another worrying message is this: the evaluation has looked at the experience of the (very few) patients who have participated in the pilot. Now of course they will say it suited them down to the ground. Practices will have been interviewed about their experience. I wonder what questions they were asked. PCTs have been interviewed: now this I very seriously doubt since PCTs disbanded in April 2013. And did they interview Tower Hamlets PCT and City & Hackney PCT, and ask them why they boycotted the pilot?

Worst of all is the fact that the evaluation is a sham as it does not evaluate the policy itself; the methodology itself is rigged to give them the outcome they wish, and to hide the very real problems that beset this brain damaged policy.

Shame on you Department of Health, shame on you Coalition Government.


14. How can they be so stupid? The Plot Against the NHS

05/06/2012

[This is the 14th in a series of 14 posts. I suggest you scroll down and start with Number 1]

The Plot Against the NHS is a book by Colin Leys and Stewart Player; I would recommend it, read it and judge for yourself.

Briefly, their thesis is that a ‘concordat’ was negotiated in 2000 by the Independent Healthcare Association with Tony Blair’s second Secretary of State for Health, Alan Milburn. ‘The Association’s leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, “to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers.”‘ (page 1)

The authors document the steps that were taken to further this aim. They call it a plot because it was covert, never made explicit, never debated. ‘Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage.’ (2)

Some excerpts:

‘So in spite of it great popularity Britain’s most famous postwar oscial achevement was unravelled through a series of step-by-step ‘reforms’ each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn the health care back into a commodity and a source of profit.’ (5)

‘Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘speacil advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Select Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.’ (5)

‘Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.’ (5-6)

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These are just a few excerpts. I have bought and read the book. To me it helps make sense of DOH behaviours which are otherwise mind-bogglingly stupid.

If you understand the ‘Choose your GP’ policy as aiming to de-regulate English general practice and open it up to for-profit companies, then it is rather clever, not stupid. But it does rely on the public being duped, and not seeing through the duplicity and deception; and the journalists, and the GPs, and other health professionals.


Letter from the office of the Deputy Prime Minister: something to show the grandchildren

02/07/2011

Letter from Office of Deputy Prime Minister

Recommend you get this book, see here.

And for another doctor’s thoughts, see here.


The plot thickens

13/05/2011

 

On Wednesday evening, I went to a talk given by David Price, co-author with Allyson Pollock of a recent British Medical Journal article How the secretary of state for health proposes to abolish the NHS in England.

In the course of his talk, he mentioned work done by the American doctor and academic Howard Waitzkin, analysing the way in which American healthcare multinationals gained entry to the healthcare markets of Latin American countries, in an effort to boost their profits. This was largely at the expense of the host nation’s healthcare system and health economy. David Price asked: this is how these companies behaved in Latin America and other developing countries, is England next?

I managed to find an article by Waitzkin and a colleague which makes unsettling reading. And it adds to the hypothesis I have outlined in the previous post.


Are the politicians and health planners very stupid or clever in a devious and corrupt way?

13/05/2011

 

For about two years I have been waking most mornings about an hour earlier than I need to with the thought, ‘How can they be so stupid?’ ‘They’ being the Wankers at the Top (WATTs) at the Department of Health (always anonymous) and their political masters. My particular reason for thinking this thought (2 years ago) was that we were being expected to implement a policy that meant self-destruction for us as a GP practice and the undermining of the quality of the service we provide, all in the name of patient ‘choice’. We solved our particular problem by simply refusing to implement this policy any further, quite openly, pointing out to the PCT the inherent flaw in the design of the policy. Then the focus of my concern became a far worse policy which takes the first policy and magnifies it 100 times: the policy of allowing people to register with the GP practice of their choice anywhere in England. Now perhaps the lay person can be forgiven for thinking this sounds like a good idea: choice has got to be better than limited choice. But for anyone who has worked as a GP for long would see that this was quite unworkable and quite mad. Hence my waking in the morning: ‘How can they be so stupid?’

In an attempt to resist this madness I started this blog, and have been laboriously emailing MPs, journalists, think tanks and anyone else I can think of to alert them to the stupidity of this idea. Everyone else has been caught up with other aspects of the Andrew Lansley’s health ‘reforms’, I have been (unhappily) focused on this one issue because it is the one that presents itself to me on almost a daily basis in everyday work.

Sunday 8 May I woke at about 5:45am; as per usual the thought appeared: ‘How can they be so stupid?’ Sometimes I am able to switch this thought off by concentrating on my breath and thinking of the sea, and I get back to sleep. Sunday morning, however, a plausible explanation came to me as to what the WATTs are up to, what the ‘direction of travel’ is in their minds. And I knew I was not going to get back. So I got up and wrote this post.

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A few weeks ago I learned about an about to be published book called The Plot Against the NHS. I read the transcript of a lecture by one of the authors which introduced the book.

I ordered the book. One week ago, while on holiday, I finished reading the book. Chilling stuff, and every citizen (and even politicians) ought to read a copy, book clubs should be formed to discuss it. But the authors did not mention this issue of registering with the GP of your choice: how did this particular policy fit into The Plot? I am trying to contact the authors to ask them.

Yesterday I spent some time at the library looking at material related to this blog: I was writing a detailed analysis of an email which the Department of Health had sent me in response to my email to the Health Ministers about 5 months ago. I re-read portions of the Department of Health’s response to the so-called consultation Choose Your GP Practice. My mind began to turn to jelly. I stopped for lunch. I went back to library, packed up my stuff, and went home. We were having people for supper. I spent the remaining time typing some excerpts from The Plot Against the NHS (to include on this blog). Then I stopped.

The human brain/mind is a mysterious and wonderful thing. One example is the way it works on stuff overnight: I go to bed feeling a bit confused or jumbled about something, and often wake the next morning with clarity and a sense of perspective. So overnight my brain/mind worked on the stuff I had looked the day before and presented me with a provisional answer this morning to the question: ‘How can they be so stupid?’

The answer is this: if they were trying to improve general practice as we know it, as it functions when it is working well, then they are quite stupid. But if they have in mind quite a different model, but one they cannot be open about because then the majority of the population would pillory them, then you would have to say they are clever enough, much like the brains behind the banking crisis (the Credit Default Swaps, CDOs, subprime mortgages) and government lobbying that made it all possible were ‘clever’. Then it makes quite a lot of sense, even if it is chilling.

So in a nutshell what my mind presented me on Sunday morning was this: taking into account the thesis presented in The Plot Against the NHS (in essence the privatisation of health care provision in England, essentially on the United States model, carried out by a number of people at the Department of Health, health think tanks, and government–all covertly over the past 10 years or so), the reason the abolishment of practice boundaries is necessary is that it then opens up primary care to large multinationals to bid for and win contracts to provide general practice services the same way that McDonalds provides hamburgers. Let me explain: let us say that Virgin want to provide general practice services. At present they have to bid for individual practices when they become vacant. In addition, these practices serve a local community, within a specified limited boundary (there are perfectly good reasons for this, practice boundaries serve a real purpose, they are not ‘anachronistic’ or outmoded or old fashioned as the Government and Department of Health say). But this is quite limiting if you are thinking of a quite different model. The model might be this: ‘Virgin Health’, a ‘willing provider’, sets up a number of primary care centres around the country (much like Virgin Active has their ‘Health Clubs’, aka gyms), at locations they feel would best suit their business model. Because you are not constrained by practice areas, anyone living inEngland can join any ‘Virgin Health Centre’ inEngland. Indeed, the ‘Virgin Health’ model might mean they have an integrated IT system so your medical record is accessible to any ‘Virgin Health’ healthcare professional at any centre inEngland. So if you are in Swindon on business, just drop into theSwindon ‘Virgin Health Club’ at lunchtime and get your blood pressure checked, and why not step into the adjoining gym while you are at it?

This model would be quite attractive to the mobile youngish person, and might provide a reasonable service for some self-limiting conditions, but it would not do what good quality British general practice does. It would not look after people who have significant health problems, and it would not look after people when they actually get sick and cannot travel to the Health Club for assessment. Not only would it not do what quality British general practice does, it would also be far more expensive. But it would of course make a lot of money for some entrepreneurs.

This, I fear, might be, the ‘direction of travel’.


The Plot Against the NHS–some excerpts

08/05/2011

 

[Here are a few excerpts from Colin Leys & Stewart Player, The Plot Against the NHS, Merlin Press; read Colin Leys’ pre-publication lecture     I would strongly advise anyone interested in the future of health planning and provision in England to get a hold of this book, and to read it. And send a copy to your MP immediately.]

 

So in spite of its great popularity Britain’s most famous postwar social achievement was unravelled through a series of step-by-step ‘reforms’, each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn health care back into a commodity and a source of profit.

Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘special advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.

Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.

(Pages 5-6)

Unfortunately the marketizers continued to advocate market models of care even when experiments showed that market-based imports were not efficient at all—as with UnitedHealth’s ‘Evercare’ programme, for example. Evercare, which the huge American HMO UnitedHealth was paid a large sum to test in four regions ofEngland, was supposed to reduce emergency hospital admissions for elderly patients by 50%. But when it was evaluated it turned out to be unlikely to cut admissions by more than one per cent. The marketizers had evidently not reckoned with the fact thatEngland’s system of primary care was already accomplishing what Evercare does in theUS, where there is no free primary care. The main lesson the Department of Health seemed to draw from this experience was not to evaluate such experiments.   (Page 8)

By 2010 marketization clearly entailed not just the possibility but the longer-run probability of privatization. Yet the fact remains that all the evidence shows that privatization make health care more costly—and worse. The evidence from theUSconfirms what economic theory says, that markets will not produce good health care for all, as the NHS is pledged to do.

A Treasury document published in 2003 clearly outline the reasons why this is so: price signals don’t work in relation to health care; the consumer lacks the necessary knowledge, creating a risk of overtreatment; there is a potential abuse of monopoly power; it is hare to write and enforce contracts for medical treatment; and ‘it is difficult to let failing hospitals go bust—individuals are entitled to expect continuous, high-quality health care wherever they are’.

Why was all this ignored? If the strategists in the Department of Health thought they had contrary evidence or superior theory they should have come out openly and said so. But they were never called on to defend their ideas, precisely because they proceeded so covertly.

A 2010 survey of 20,000 patients in eleven industrialised countries for the US Commonwealth Fund found that the NHS was almost the least costly healthcare system of them all, and at the same time gave one of the best levels of access to care. Other countries not only spent more per head but also charged patients directly, reducing equality of access. OnlySwitzerlandreported faster access to care, butSwitzerlandalso spent some 35% more per head than theUK. OnlyNew Zealandspent less per head, but one in seven New Zealanders said they skipped hospital visits because of cost. To ignore all this evidence and embrace the idea of replacing one of the most cost-efficient health systems in the world, as well as one of the fairest, with one modelled on the most expensive and unequal system (the American), sets a new standard for ideologically-driven (and interest driven) policy-making.

But the NHS has not only worked well, providing high-quality, equal care for everyone, free of charge, at low cost: it is also the historic achievement of millions of people—those who fought to establish it, those who have spent their lives working for it, and everyone who has paid their taxes to build it up over the more than sixty years since it was created. Its founding principles of comprehensiveness and equal access for all have been core values of modern British society. Working to marketize it, and finally privatizing it, without any democratic mandate—without even explaining that aim to parliament of the public, is as close as it gets to being not just unscrupulous, but actually unconstitutional. The question is whether the English people—Scotland,Wales, andNorthern Irelandhaving escaped the plotters’ reach—will accept having this precious part of our heritage filched from under our noses.

(Pages 9-11)


Practice boundaries an anachronism according to King’s Fund?

08/05/2011

 

One of the things that has puzzled me about the Choose Your GP Practice issue has been the almost total lack of challenge from the journalists reporting the various ministerial statements on this issue. I have seen no articles commenting critically on this policy. This is strange because it is such a crackpot policy. I was aware that Andy Burnham gave a speech in September 2009 on this. I tracked it down: he addressed The King’s Fund and, according to the Guardian he said this about choosing your GP practice:

“In this day and age, I can see no reason why patients should not be able to choose the GP practice they want. Many of us lead hectic lives and health services should be there to make things easier.”

I have listened to the the 51 second video segment on the Guardian page. He does not seem to understand how general practice works, or why there are practice boundaries. His arguments are quite arbitrary and irrelevant. I wondered how this ‘important speech’ was received at the King’s Fund. The video of the full speech is thankfully available from the King’s Fund along with panellists’ responses to the speech. Unfortunately, in the available video footage there is no mention made of GP boundaries.

However, in his closing remarks the chief executive of the King’s Fund, who I believe had chaired the meeting, had this to say:

On the plan to make it easier for patients to choose their GP, Niall Dickson said: ‘The vast majority of patients are more than happy with their GP, but the restriction on where they can register is an anachronism and the government is right to sweep it away. There are details to be worked out, but it should not be impossible.’

Anachronism? I would like to know in what sense. ‘Details to be worked out’? I would be curious to know what Niall Dickson had in mind.

I wish I had been present for this speech and discussion. I would have like to have asked the audience if they all agreed with this, check if there were any dissenting voices. And if not, suggest that if they really want to warrant the name ‘Think Tank’ that they do some homework and think this policy through.

The King’s Fund says this about their role and aim:

The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas. 

Niall Dickson is no longer at the King’s Fund. He is now in charge at the General Medical Council. I emailed him there, asking for clarification though I think I will not receive a response. I emailed the King’s Fund a week ago asking for their views on practice boundaries, and how this might affect the health system in England. I await their response.