Lansley promise 2011: “NHS patients will be able to pick consultant”. September 2015: Where are we now?

26/09/2015

An article appeared in The Independent in October 2011 which reported that Andrew Lansley was going to make it possible to pick the hospital consultant of your choice. It seemed to me to be a moronic idea at the time and you can see why in a post I wrote at the time. (In fact, I discover that I wrote an earlier post pointing out the absurdity of promises made in the White Paper which then led to the Health and Social Care Act; it is worth looking at both these posts in view of where we are now.)

So where are we now? Let me tell you how it is for me, referring patients to hospitals in London. Yesterday I spent about an hour trying to arrange an appointment for two patients failed by the system, entirely predictably. One concerns Patient X who has chronic back pain who has had an MRI scan of her/his lumbar spine, and the report recommended referral for possible spinal surgery (I asked for advice from our local spinal orthopaedic surgeon, he advised referral); the other concerns a baby under 1, referred to a London centre of excellence.

I referred Patient X six weeks ago through the Choose and Book system (recently rebranded as the NHS e-Referral Service). What choice did Patient X have? Well, there are two avenues for this sort of situation: a spinal orthopaedic surgeon, and a spinal neurosurgeon. I tried the orthopaedic surgeon first. The wait for our local spinal orthopaedic surgeon at the Royal London Hospital was 185 days (that is, over 6 months); there were not many other options, with similar waits. So I tried spinal neurosurgery. Here the choice was even more reduced, but there was one option: an appointment in 41 days at the National Hospital for Neurology and Neurosurgery. I clicked this option, printed the form and gave it to Patient X to book the appointment online.

When Patient X tried to book the appointment, there were no appointments; Patient X was told that she/he would be contacted by the hospital within 2 weeks regarding an appointment. This did not happen. So Patient X rang the NHS e-Referral Service; they could not help her/him, she/he needed to ring the hospital. Patient X rang the hospital and was told the they would contact her GP to confirm that a referral was necessary (a strange step as I had referred Patient X in the first place). In any event, I did not hear from the hospital.

So yesterday I rang the NHS e-Referral Service. They could not help me, it was out of their hands. I did point out a generalised problem, which was illustrated by the individual case of Patient X. In my experience, whenever the patient finds there are no listed appointments and are told they will hear within two weeks, it usually means an appointment will not be forthcoming; & when the patient pursues it with the hospital they will eventually be told there are no appointments and to go back to their GP (!). And then what I do is start again: I raise another referral through the e-Referral Service but warn the patient not to choose an option that does not give them an actual appointment. So yesterday I spoke with a manager at the NHS e-Referral Service and I told her about this problem. Initially she was evasive and defensive, but then softened and agreed that in these cases the system did not work. I suggested she take this back to her organisation and ask that they at least be honest about this issue and warn patients booking with hospitals who do not have appointments listed.

I then rang the Hospital for Neurology and Neurosurgery. I explained the situation; that the patient had been told I would be contacted; that I had not been contacted. On the NHS e-Referrals system, Patient X’s referral is currently categorised as ‘Deferred to Provider’. The staff member at the Hospital for Neurology and Neurosurgery said that this meant me, her GP. I said I did not think so; I thought it clearly referred to the hospital to whom I had referred the patient. I was then advised to fax a copy of my referral letter to the staff member and that she/he would pass it on for vetting.

With respect to the baby, exactly the same thing has happened. No appointment. Parents told to go back to their GP. I have made a new referral, and chosen only providers who actually have appointments. (The hospitals without current appointments will be listed as ‘Unknown’ as the date of next appointment).

This situation is not unusual. With respect to my local hospital, the Royal London Hospital, many specialties have long waits or are ‘Unknown’. My impression is the ‘Unknown’ category is actually a way of avoiding these referrals appearing in the statistics; if the hospital were to give an appointment that is more than so many days, then that is a breach of the targets and there is a financial penalty. So if they do not give an appointment, if they tell the patient to go back to their GP, perhaps they avoid this breach. I think it is likely that this is what is happening. I could of course chase this up further and get to the root of the problem, but I am a GP, not an investigative journalist (not many of them around these days). Our CCG sent us Tower Hamlets GPs a letter recently advising us not to refer to certain departments at Barts Health since they are having considerable problems with capacity. This is all very well, but then we refer to alternatives like the Homerton Hospital; and it does not take a genius to realise that these alternative providers also face the reality of capacity and their waits will lengthen and possibly/probably go beyond the target and then breach and be financially penalised.

So there is quite limited ‘Choice’; what Lansley and the DoH promised was moronic from the start, the current situation was entirely predictable. Is it the hospitals’ fault? No, it is an absurd Herculean task. What we need is people to be honest about this, to fight back and point out the absurdities in the demands being placed on NHS services by Morons in Government.

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For a picture of London spinal neurosurgery referral options as of yesterday, Spinal neurosurgery options on 25.9.15.

 


My second email to Jeremy Hunt on the fraudulent GP practice boundary policy

13/10/2013

Dear Jeremy Hunt,

I sent you an email on 8/9/13 raising concerns about a Government policy. I received a ‘reply’ from a Department of Health official (for my original email and the reply, see below). A first year GCSE student would have no trouble seeing that this is no reply at all: it is a bland, seemingly innocuous, description of the ‘pilot’ into general practice without boundaries. It does not address my concerns at all (1).

I ended my first email with a quote from my submission of May 2013 to the Health Select Committee:

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 (2).

The DH reply only reinforces my hypothesis that this policy is a scam, a deception, a confidence trick.

*

I have been following the development of this policy for over 3 years now. I have not been able to find an example, a metaphor, which would help people to understand the sheer stupidity of this policy. And then last week I came across a news item that I think is of help. Briefly, it is this: a British entrepreneur was convicted in April 2013 for fraud; his fraud was selling bogus bomb detectors to the Iraqi government. He made a lot of money; the bomb detectors did not work; innocent people were blown up; these bogus devices are apparently still being used in Iraq to ‘protect’ the citizens.(3)

I believe this story, this parable, offers a structure that helps make sense of the policy which you, as Secretary of State for Health, have inherited. There is a product, a technology, which is said to perform a function (detect bombs, avoid disasters); the technology is marketed (presumably there was promotional material; presumably it came in a box with reassuring messages on the box); the buyer is persuaded to pay for the technology; the technology is put to use; the technology does not work.

(This sad, shocking story raises a number of questions which I will not address here; but one question is this: why did they not test the device? Presumably the entrepreneur and his firm told the buyers that it had been tested, perhaps they said the device was already being used in other war zones).

Now let us come back to the policy of abolishing GP practice boundaries. British general practice is a complex technology which by its very nature is local, geographically based. Our experience has been that when people move away from the practice area it is no longer possible to look after them properly, especially if they are unwell. So when I heard politicians saying that boundaries were old fashioned and limited choice I was bewildered. I heard Andy Burnham say that this policy would transform the NHS from ‘good; to ‘great’, that poorer patients would be able to take advantage of services that were offered to richer patients; I heard them say that this policy would promote competition and that this would drive up quality. Most of what I heard was very foolish, it did not make any sense, it was nonsensical, it would simply not work, it would not deliver what they were promising, it would actually undermine our work.

Now just in case you think I am some sort of eccentric, some nutty GP who has an absurd bee in his bonnet, ask yourself this: why did the former GPC Chairman Laurence Buckman describe this policy as ‘bonkers’? And why did the annual LMC conference in 2011 vote unanimously (something unheard of) a motion urging the GPC to resist this policy ‘staunchly’?

So, Mr Hunt, what I am saying is this: the technology your Government are proposing simply does not work. Your predecessors, the various promoters of this policy (politicians, the Department of Health, aided by compliant journalists and think tanks) have presented the public with an attractive box, with catchy packaging, which promises a great technology. But the device in the box is bogus, it does not actually work. Just like the bogus bomb detector. They have done no honest testing of the technology in the box. You pretend to test it, as with the sham pilot and the questionable ‘evaluation’ (4).

You see, Mr Hunt, I understand the technology. This is my area of expertise. And I am saying that the technology that your Government is promoting is very faulty and it will not deliver what you are promising. Either you are all remarkably stupid or you are perpetrating a fraud.

The entrepreneur who committed the bogus bomb detector fraud has been arrested, charged, convicted, and sent to prison for his fraud (but not, apparently, for the harm he has caused to a large number of people).

If I am correct in my hypothesis that the Department of Health and ministers are engaged in a deception, a fraud, then should they be charged? And if not, why not?

So what do I propose? I propose that the Health Select Committee open the box and scrutinise the contents carefully, honestly, dispassionately. But are they capable of doing this? I am sceptical. When the Chairman of the Health Select Committee, Stephen Dorrell, was phoned by a Pulse journalist following my submission in May, he said he was broadly in favour of the policy: ‘Where there is choice different people will have different ways of solving the problem and provided that they are all consistent with the commitment to universal delivery of high quality care then I think that the [option] which allows people to consider different ways of solving shared problems is in the interests of all patients.’ (5) This is typical of the rhetoric that is used when discussing this issue; the word ‘choice’ is inevitably used, ‘high quality’, ‘interests of all patients’. But it means nothing. It is all packaging, spin. It does not address the technical problems at all. Mr Dorrell needs to open the box and look at the technology inside the box, not to approvingly describe the packaging.

There is of course another very important question here that I feel, as a professional and as a citizen, needs to be addressed. What is wrong with the system that we have come to this? How is it that policy has been allowed to develop in this way? This is not just a ‘blunder’.

So perhaps it would be better for an independent body to look at what is in the box.

I would also propose that journalists wake up. Look inside the box, ask if it really performs the functions that the promotional material claims (but, for heavens sake, do not use the DH as your source of information). Ask questions; educate yourselves, try to understand the ecology of UK general practice. If any of you are interested, I would be happy to take you through the issues in plain English. Who knows, there might be an Orwell Prize at the end of it all.

Mr Hunt, you have a real problem here. If you implement this technology the problems will become apparent, the design faults will be exposed. You will no longer be able to fall back on the attractive box and the glossy promotional material. You will not be able to say you were not warned.

In the end, Mr Hunt, you cannot get away from this reality, eloquently stated by Richard Feynman: ‘For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.’

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

Notes:

1. The reply from the DH: for reply & my comment; for my first email to Jeremy Hunt
2. For my Submission to the Health Select Committee
3. Bogus bomb detector fraud
4. Questionable ‘evaluation’ of pilot
5. Pulse article ‘MPs to investigate GP practice boundaries’; I do not think they have actually investigated this issue. Nobody has called me, I have not seen it mentioned in the announcements from the Health Select Committee.


NHS Choices Website: my attempt to leave a comment regarding ‘Patient Choice Scheme’

14/04/2013

A few weeks ago, I found the NHS Choices page promoting the ‘Patient Choice Scheme’. I registered and left this comment:

I am a GP in Tower Hamlets, one of the sites chosen for this pilot. What the Department of Health is not telling you is that two of the 6 sites above (Tower Hamlets and City and Hackney) have refused to take part in this pilot in order to protect the local health economy and services to our local population.

The proposed policy to abolish GP practice boundaries is deeply flawed, but the Department will not tell you that.

For more information, see www.gpboundaries.org

*

I checked this afternoon, and noticed that my comment (which I thought had been accepted on 31/3/13) was missing. There are in fact no comments to this page. So I have tried again. My Comment on Choices website but somehow feel that it won’t be visible, ever, to anyone else.


‘If you want to sell a lie, get the press to sell it for you…’

17/03/2013

Yesterday evening, after working all day to catch up on the infinite amount of backlog, my wife and I went to see the film Argo. At one point in the film, one character begins a sentence, ‘If you want to sell a lie….’ which is then finished by another character, ‘get the press to sell it for you.’

This seems to me to sum up well the role of the Department of Health Mediacentre during ‘selling’ of the Health and Social Care Bill.

More specifically, it is at the centre of the ‘selling’ of the policy to abolish GP practice boundaries. I used to think the politicians involved and the Department of Health were just remarkably stupid. I have now come around to the view that they are not stupid, they are carrying out a deception. What they really want is to deregulate English general practice, to make it boundary-free.

Why? Ask Virgin Care, KPMG, and McKinsey.

For examples of what I mean, read my article on Andy Burnham’s visit to the King’s Fund (and the blog post providing notes to this article), and my article about the press’s striking compliance with Department of Health’s Media Centre.


Will the real Neal Bacon please stand up?

09/03/2013

I had not heard of this man until yesterday. There has been some Twitter activity about him today, much of it raising questions. I followed some of the links.

There is enough to raise questions about his credibility, and ask for some clarification.

His blog claims he was a ‘nephrologist’, Harvard and Oxford trained. I would like to know what this means. I would like a list of the jobs he has done. Does he have MRCP? How high up the training ladder did he go? According to the GMC site, he is   a registered doctor, fully registered in 1991, but not on the Specialist Register. So is he misrepresenting himself?

I came across this blog entry from 2008. (This is what sent me to the GMC; you can check his registration, just enter name and surname).

And then this helpful page from Dr Rita Pal.

And then, ironically, given his enthusiasm for patients rating their doctors, this page where patients rated him 2.2 out of 5. But God only knows what that means.

 

 

 


Neil Bacon’s misunderstanding about how general practice works

09/03/2013

The name Neil Bacon came up in Twitter yesterday. Roy Lilley thought at one point that he had written Jeremy Hunt’s speech at the Nuffield Trust summit. I looked him up and, lo and behold, he had just written an article about general practice and the need to abolish GP practice boundaries. So I had to stay up late and post a reply on his blog, his Telegraph article, and the Telegraph journalist’s article.

Neil Bacon is an entrepreneur (says so on his blog; the Biography page is so far empty so I don’t know what experience he has with primary care). He is selling a product, so obviously he will promote himself and his product.

This is what I posted on his blog piece:

I am sceptical about much of what you write. It’s all a bit too black and white.
I know quite a lot about the issue of GP practice boundaries and here you are on very shaky ground. I work in a practice which in one report was cited as the one with the highest satisfaction rating in Tower Hamlets. Yes, this was gratifying but we are in no position to accommodate patients wanting to join us: we are unable to register all the patients within our practice area who want to register with us so we are certainly not able to register those who live outside that area. In addition to this limitation, we also have over 20 years experience that tells us that looking after patients at a distance from the practice is full of problems and at times unsafe.The drive to de-regulate general practice by removing geographical boundaries will benefit some mobile relatively healthy patients (and Virgin Care) but it will actually create a systemic mess and harm many.If you are willing to have your views challenged, see http://www.gpboundaries.org(For the record, I think serious efforts should be made to improve the standard of general practice across the board so that everyone, wherever they live, has access to a ‘good enough’ GP practice, but that would require other strategies which nobody seems to be talking about.)

*
For the record, my comment to his Telegraph article was this:
I am a GP in Tower Hamlets. My practice gets high patient satisfaction ratings, and we score relatively highly on the various outcomes ratings. We would like to do better, but are struggling in difficult times.
I think the public needs to be warned about the illusion of choice, which Neil Bacon seems to subscribe to. There was an article in the local press saying that our practice had the highest satisfaction rating in Tower Hamlets http://bit.ly/UBdGfk
In Neil Bacon’s universe this would mean that patients from the lower rated practices could move to our’s. But there is a simple, very basic problem with this: we are currently working at full capacity, in fact exceeding our capacity. We are unable to register all those within our geographical area who wish to register with us. In fact, we recently had to shrink our practice area. So eliminating GP geographical areas will not suddenly allow you to register with the GP of your dreams.
There is another reason you need to be aware of: general practice in the UK is a community-based technology, it looks after communities which are local. The ecology of general practice is such that looking after patients who live at a distance introduces a large number of problems, and is at times unsafe.
New Labour launched the idea of abolishing GP practice areas, Andrew Lansley has always backed this idea. As a GP who is committed to providing good quality primary care to our patients it is a mad idea. It sounds like a good idea, a no-brainer, but when you look into it it just does not add up. I think the politicians are either remarkably stupid, or they are actively deceiving you. And journalists have been duped.
For anyone wanting to look into this further, see my blog www.gpboundaries.org
(Yes, I think every effort should be made so that all have access to a local ‘good enough’ GP practice, but this market driven model is, I think, not the answer. In fact, it will make things worse.)

My email to Health Select Committee on GP practice boundaries-Grotesque stupidity or deception?

01/10/2012

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?

Best wishes,

George Farrelly

BA, MSc, MBBS, MRCGP
The Tredegar Practice
35 St Stephens Road
London E3 5JD

www.onegpprotest.org

“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