8. How can they be so stupid? Duplicity

05/06/2012

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)


7. How can they be so stupid? Deception

05/06/2012

The Oxford Dictionary of English has very little: act of deceiving someone: obtaining property by deception

Wikipedia is much richer here:

“Deception, beguilement, deceit, bluff, mystification, bad faith, and subterfuge are acts to propagate beliefs that are not true, or not the whole truth (as in half-truths or omission). Deception can involve dissimulation, propaganda, and sleight of hand. It can employ distraction, camouflage or concealment. There is also self-deception as in bad faith.”

Yes, this is very helpful. I read this description, this list, and I think spontaneously of the New Labour Government’s so-called ‘Consultation’ on the issue of choice of GP, launched in March 2010. The documentation accompanying the ‘consultation’, and the ‘questionnaire’ were clearly designed to lead to a ‘yes’ vote. And then now, the Department of Health, and Lansley, use the ‘results’ of this ‘consultation’ as one of the main planks supporting their policy. I believe that this ‘consultation’ was quite misleading, an act of deception.

No doubt this will cause consternation in some quarters. Fine, read the documentation. Ask yourself this: is this balanced? what is the message? what are the omissions? what are the risks of this policy (hardly any mentioned)? are the questions in the questionnaire ‘leading’ ones? ask an (independent) expert in polling what they think of the format of the ‘questionnaire’.

To get a taster, read the patient leaflet. For the full document (the Questionnaire starts on page 45).

For full Wikipedia article on deception

Yes, I must add ‘bad faith’ to the original list.


5. How can they be so stupid? Ignorance, wilful and unwilful

05/06/2012

With the issue of GP practice boundaries, there is in general a very limited  understanding about general practice actually works, about how good quality general practice works. Even our hospital doctor colleagues often do not understand how it works.

Good quality British general practice is a very complex technology which serves local communities in geographical areas. You need to have an understanding of this and how it works. Otherwise, you are ‘ignorant’.

A GP colleague of mine has been to a number of events organised by the Department of Health in recent months. She has been struck by how ignorant the people from the Department of Health are about how general practice works, how general practitioners work, how good quality British general practice works.

‘Wilful ignorance’: don’t confuse me with the facts.


4. How can they be so stupid? Naivety

05/06/2012

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

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

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

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


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

05/06/2012

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

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

Naivety

Ignorance (wilful and unwilful)

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

Misinformation (wilful and unwilful)

Deception

Duplicity

Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)


2. Why pursue this issue of practice boundaries?

05/06/2012

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.

 


‘Choose Your GP’ pilot: a confidence trick?

04/06/2012

4/6/12:

There are two main problems with the ‘Choose Your GP practice’ idea, proposed by all 3 main political parties, and welcomed by many well-meaning patients and patient groups who are frustrated in many ways by the current state of affairs. The first obstacle is that of capacity: most practices are currently working at full capacity. There simply is not significant spare capacity at that wonderful practice you have heard about 15 miles away. The second problem (and this covers a myriad of issues) is that looking after patients at a distance from the practice does not work: it is ok for people who are well, organised, and mobile, but not for people who are sick. This is how it is. Policy makers have to accept and work with these facts of nature.

In the press release on 30 December 2011 (why choose such a date?), we read:

“Busy commuters will benefit the most from the new pilot scheme, which 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.

The announcement means commuters in the pilot areas, who are often away from their local area during the working day, will find it easier to see their doctor where it suits them, and receive the same services as in their old practice.

The pilot, which will begin in April 2012 and last for one year, will also come as a relief to people who are moving home and wish to remain with their preferred practice, and families who would like a practice near to their children’s school.”

The press reported this, just reproducing, without any questioning or any irony, what the DOH press office gave them.

Where are we now? The launch had to be delayed by a month while the DOH ironed out some practicalities, and then the East London LMCs wrote to GPs advising them to boycott the pilot unless it was properly funded, then the recent LMC conference (if I am not mistaken) voted to reject the pilot. And then we have a robust report (see link below) commissioned by the Corporation of London and NHS London North East and the City analysing the primary care needs of the City of London with its resident population of 11,700 and one GP practice within its area, and approximately 360,000 working population who might want to avail themselves of Andrew Lansley’s offer. It is obvious that the current primary care infrastructure in the City of London is in no position to provide what Lansley and the DOH have offered. What were they thinking?

There was a Czech documentary in 2004 (Czech Dream) which perpetrated a hoax on the Czech public, with advertising for a hypermarket due to open shortly. But there was no hypermarket, just a life-size poster of a hypermarket held up by scaffolding. A crowd of several thousand gathered in a field for the ‘opening’, attracted by the promised sales, and ran across the field after the ribbon was cut.

In some ways, a similar dynamic is at work here. But I am not sure if Lansley or the DOH themselves are aware of the con. It is not reported in the press.

Report on City of London primary care needs

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30/1/15: The policy was in fact launched on 5/1/15, very quietly. It is a mess. Czech Dream, English Dream.


East London LMCs advise boycotting ‘Choose Your GP’ pilot

21/04/2012

Pulse has published an article on this, together with the letter.

My comment to the Pulse article:

Congratulations to the East London LMCs for taking this necessary step. Not only will the commuters using local GP practices be using local resources in terms of secondary care, community services, and prescribing costs, but do local practices really have the capacity to look after these additional patients without distracting them from their local registered populations?

PCT clusters throughout England are having to put in place contingency plans to look after patients who register at one of these pilot sites, but who then fall ill at home and need a GP. What is the cost of all of this? Where is this money coming from?

At all sorts of levels this is a crackpot policy. Either Lansley and the secret agents at the Department of Health are remarkably stupid, or, more likely, this policy is actually a smokescreen to de-regulate English general practice. Removing practice boundaries will open up general practice to an entirely different model which will be ‘liberating’ for organisations like Virgin Care, but will undermine British general practice.

They call this a pilot and they say that it will be ‘independently’ evaluated. I predict that as with other piloted policies, that plans to implement the nationwide roll-out will be made before the (sanitised?) evaluation is made public.

I believe it is possible to stop this policy, but this will require persistent clear-headed resistance to the impracticalities & inefficiencies that will inevitably be proposed. A light needs to be shone on this policy: why did none of the 3 political parties carry out a proper risk assessment of this policy? Why did the Department of Health avoid almost any mention of these risks in the so-call ‘Consultation’ two years ago?

It is really just a confidence trick, and the choice it promises is an illusion. The GP you’ve heard such good things about is actually working at full capacity already. The well-functioning practice you may have heard about works well with this population size, within this geographical area. Increase the list size, change the geography, and the system changes.

For more on this, see my blog www.onegpprotest.org


Email to MPs surname beginning with L: message/protest/warning from indignant GP in Tower Hamlets

12/02/2012

I am a hardworking GP in Tower Hamlets. My aim is to try to provide good quality primary care services to the local population of Bow.

I am indignant: you politicians and your colleagues at the Department of Health are designing policies which make my job harder, if not impossible. You dress it all up with words like ‘Choice’, ‘modernisation’, ‘reform’: but much of it is really just ‘sabotage’.

I am indignant: you are using a very stupid methodology. You avoid looking at risk; in fact, Andrew Lansley has gone so far as to keep risk secret. And you just seem to accept this. Is this intelligent?

I have been running a protest blog for the past year, and writing to MPs, one letter at a time. Now is the turn of the L’s. I know there is a convention that you don’t deal with issues raised by people who are not your constituents. (Do you read newspaper articles by people who are not your constituents?). Consider me a lobbyist then. I am lobbying on behalf of good quality English general practice. Am I paid to do this? No, it costs me. Do I stand to gain financially? I don’t think so.

I am doing this because I am indignant. This email, my blog, my activity on Twitter, is my protest, my tent pitched in the square.

My protest, my focus has been primarily on the issue of GP practice boundaries.

All 3 main political parties are in favour of the policy of abolishing GP practice boundaries, and allowing people to choose their GP practice without the constraints of geography, anywhere inEngland. When I first heard this proposal over 2 years ago, I could not believe that anyone would propose such a thing, so mad did it seem.

I will be brief, and if you want additional information, go to my blog. See links below.

1. You would think that anyone drawing up a proposal to change the structure of general practice inEnglandwould do some sort of robust assessment (including risks, unintended consequences, etc.) before launching the policy in public. This is basic, I think you would agree. Yet for this policy, there is no evidence that the Conservatives, Labour, or the Liberal Democrats ever did a risk assessment. I emailed Andrew Lansley in March 2010 and with some difficulty extracted the evidence that they had not carried out any risk assessment or feasibility study. New Labour and Andy Burnham’s evidence lies in the Department of Health’s documentation surrounding the so-called ‘Consultation’ Choosing Your GP Practice, launched in March 2010. This documentation lacks any serious examination of risks and unintended consequences. The documentation is essentially a PR exercise designed to elicit a ‘Yes’ to the questionnaire, which politicians have since used as ‘evidence’ that the people of England want to be able to choose a GP practice anywhere in England. Indeed, on more than one occasion, Andy Burnham has said, ‘I can see no reason why people cannot register with the GP of their choice.’ Not even one reason: clearly, Andy Burnham, despite being Secretary of State for Health, had not done a risk assessment. And he continues to say this sort of thing, as recently as December 2012. I have asked the Liberal Democrats (more than once) for any evidence that they carried out a risk assessment; silence.

This sloppiness, recklessness, arrogance: it makes me indignant, very indignant.

2. Your policy promises to give the people of England greater choice, ‘real choice’ as Andy Burnham has said. This choice is really an illusion. What you must understand is that the vast majority of GP practices are currently working at full capacity. They do not have spare capacity to absorb significant additional numbers of patients. Your idea is that the popular, well-performing practices that offer a good service will attract patients from the poorly-performing practices. This will simply not work, not to any significant degree.

Indeed, there is a risk that local people will not be able to register with a local practice because people outside the practice area have taken up part of the limited capacity. So far from doctors competing with each other, we will have patients competing with each other for places in a desirable practice.

And if you force practices to register all comers (as is currently the case with the 2004 GP contract), then the standards will fall.

Politicians and the Department of Health simply do not seem to understand the reality of capacity, and its relation to quality. This is very basic. It is shocking that an organisation that is supposed to organise a National Health Service should be so stupid.

Put another way, it is essentially a zero sum game. For some there may be some scope for expansion, but this will have its limits. Perhaps you can understand this if you think of the game of musical chairs. There are a limited number of chairs, more or less enough for the English population. Your modelling appears to assume the chairs are unlimited.

3. Then there is the reality of how general practice works: it is a local technology. The service works for a local community, and has links and networks to local services. We have worked in our community for 21 years. When people move away, they try to remain registered with us; our experience over the years is that this does not work, and is at times unsafe. I give examples of this on the blog.

To actually restructure things so as to remove the locality-base means to destabilise how the system works: it leads the system to malfunction.

You think you are doing something good when in fact you will cause a system under a fair amount of strain to malfunction: you are unwittingly sabotaging primary care. And you call this ‘modernisation’.

This too makes me indignant.

4. Let me return to capacity and quality, which is another focus of my protest on the blog. The current rules on patient registration is that we should register anyone in our practice area who wishes to register with us (=patient choice). But we found that this would destroy us; so we decided, unilaterally, to refuse to do this. We keep our list size at about 3,520; as people leave the area and the list, we register new patients. We have been quite open with the PCT and the LMC. The reasons are documented on the blog. I wrote to the Department of Health about this, and met with the then GP ‘tsar’. He agreed with me that this was not a sustainable situation, and said this was not a national policy but a local mistaken application of a national policy. I did not think this was the case. I asked who was responsible for this policy. He did not know. He did not offer to find out.

The recently published guidance to PCTs on the implementation of the pilot for commuter patients in 3 English cities (Tower Hamlets is included in the pilot) reiterates this directive: what we are currently doing is prohibited. We would have to either have to take all comers or shut the list to everyone (with the permission of the PCT). The guidance says that otherwise patients get confused. In our experience, patients understand this entirely and are not confused by it.

This is a very stupid policy and we will continue to adopt a stance of civil disobedience, and protest against it.

This too makes me indignant.

5. So if abolishing practice boundaries is so stupid a policy, why are they doing it?

There is a hidden agenda. What I believe this is really about is the deregulation of English general practice, the marketisation of general practice. Whilst the Department of Health goes on and on about patient choice, the true incentive is this: by eliminating practice boundaries, it will allow for profit organisations to set up primary care centres which can register people regardless of where they live. These centres will have no commitment to a community, to a locality. They will be based in city centres and their patients will be the healthy and mobile. If these patients get sick and are unwell at home, the centres will not have to look after them because they will not be local, they will be at home. Someone else will have to provide care for them where they live. (See the Department of Health guidance document, section 6).

Abolishing practice boundaries will ‘liberate’ the NHS for these entrepreneurial groups. These will essentially be glorified walk in centres catering for the healthy.

This too makes me indignant.

6. The proposed policy to abolish GP practice boundaries is a relatively small part of the Health Bill, and not on most people’s radar. But for general practice it is a very important issue.

The opposition to the Health Bill is growing inexorably. Even Tories are worried about the fall out. Andrew Lansley and David Cameron say they are determined to soldier on.

Let me give you a warning from the front line. Much of this Bill is built on PR: Choice, Modernisation, Reform of the NHS. Whenever Andrew Lansley or David Cameron or Simon Burns are questioned about an aspect of the Bill, these words will be central in their answers.

But what lies underneath all this? My wife is a member of the Tower Hamlets CCG. She is committed to trying to commission good services for the people of Tower Hamlets, but she thinks the structure that Andrew Lansley has designed makes the project unworkable.

I have studied the practice boundary issue carefully. It is a scam. My suspicion is that other aspects of the Bill are also scams.

If you push this Bill through, which seems to be the likely outcome as I write, things will unravel. They will unravel because built into their design are flaws. If this Bill was a building, it would not stand up, it would collapse. If it was a bridge, the bridge would collapse. So things will begin to malfunction, and it will be clear to all of us that they are malfunctioning because of design faults which are your responsibility.

At that point, the penny will drop. People will realise that they have been had, that all the rhetoric was just PR, emperor’s new clothes. And there will be anger; and this anger will be directed, rightly, at you. The warning signs are there: you can choose to pay heed, or you can plough on.

Reflect on this statement by Richard Feynman, the physicist, which I have adopted as the motto for my blog: ‘For a successful technology reality must take precedence over public relations, for nature cannot be fooled.’

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Links:

1. My email exchange with Andrew Lansley

2. The problem of patient registration policy, in a nutshell

3. Your Choice of GP: the problem in a nutshell

4. The problem of caring for patients at a distance; examples

5. Email exchange with an MP attracted by the idea of being able to choose a GP at a distance

6. Email exchanged with The King’s Fund on GP practice boundaries

7. Department of Health Choice of GP Practice – Guidance for PCTs Jan 2012

8. Department of Health’s ‘Consultation’ PR exercise Your GP Your Choice Your Say


Choice of named consultant-led team: another moronic policy from Lansley & DoH

05/11/2011

I was aware of this proposal, as it had been listed in the White Paper, in the same list as the right to choose your GP practice, no matter where you lived. At the time I thought it was a mad idea, and I still think it is mad. How mad? If the KGB had infiltrated the DoH and parliament with operatives whose mission it was to make various services within the NHS malfunction, then this would make sense. It is as moronic as asking a GP practice to register anyone wishing to register with them, irrespective of capacity. The same dynamic is operating here, the same muddled thinking. If a first year GCSE student handed this proposal in as part of his or her course work, one might reasonably expect it to be handed back for further amendment.

Essentially, the problem is this: as GPs we refer patients, when appropriate, to a hospital specialty service (say gastroenterology). Several years ago, we wrote letters to named consultants (usually, but not always, in a local hospital); or we would address it to ‘Consultant Gastroenterologist’, Local Hospital, Main Street. For a few years we have been referring through an online system called Choose and Book: this is, with rare exceptions, a referral to an unnamed consultant within a named hospital. This new development proposes to have the consultants named on Choose and Book so that patients can choose who to refer to. This is a perfectly welcome development because as a GP I often have a preference myself which I would suggest to the patient. However, we run up against the problem of capacity. If too many people request to be sent to Dr Popular’s team, then that team will not be able to continue the same quality of service. The quality will fall. The waiting times will lengthen; because there are maximum permitted waiting times, locums will have to be drafted in. And let me tell you, the quality of doctors you will obtain in this way is patchy: they might be excellent, they are more likely to be be mediocre. I have outlined this problem in more detail in a previous post, if you are interested.

On Wednesday October 12, 2011 I read the following brief article in the Independent (the online version has it at the end of another article, link below if interested):

NHS patients will be able to pick consultant

NHS patients needing specialist treatment will for the first time be able
to choose the consultant to whom they are referred, Andrew Lansley announced
yesterday.

In a significant extension of patient choice, hospitals will be required to
accept all “clinically appropriate referrals to named hospital
consultant-led teams”.

Patients will be able to travel to any part of the country to see the
consultant of their choice and hospitals would be required to publish
individual “success rates” for their specialists to help patients
choose, the Department of Health said.

The announcement, timed to bolster public support for the Health and Social
Care Bill during its Second Reading in the Lords, brings NHS patients into line
with private patients who already have the right to choose a named consultant.

But it marks a divergence from past policy which prohibited named
consultant referrals to keep down waiting lists.

Rating individual doctors’ performance has also been rejected in the past
on the grounds that modern medicine is a team activity and individual
performance measures would be misleading.

Sir David Nicholson, chief executive of the NHS, interviewed in 2008, said:
“It’s the team that makes the difference, not the individual. The days of
the heroic surgeon, like Sir Lancelot Spratt, are long gone.”

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I can only assume that the text of this article is more or less listed verbatim from the DoH press release. Now I know as a referrer that this policy will simply not work, that it is moronic. But what made me shake my head was this idea that the announcement of the policy was “timed to bolster public support for the Health and Social Care Bill during its Second Reading in the Lords”. Now if the Lords were to be swayed by this news, then they too must be pretty moronic. The article is filled with very odd statements which don’t really make sense. For example,  the policy “brings NHS patients into line with private patients who already have the right to choose a named consultant.” Of course they have a choice, it is a private arrangement and they are able to see the consultant of their choice provided their insurer has that consultant on their list. But what the press release fails to say is that in the private sector there is no requirement whatsoever for that private consultant to see all patients within a certain amount of time. There are consultants in the private sector who have long waiting times; people will wait because they want to see that consultant, or they will go to another consultant. And they will see that consultant personally, not some junior member of his or her team.

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I had planned to email a consultant at my local hospital just to check with him whether I was missing something, whether there was new efficiency technology or ‘new physics’ which made this policy possible. I would have promised not to reveal his identity. But then I met had a conversation yesterday with a colleague on one of the London CCGs who told me that he had been told by a manager at one of the London hospital trusts that they were awaiting guidance as to how to implement this policy, who felt it was just not possible, that it was Kafkaesque.

So if there are any hospital consultants out there (or, indeed, a DoH operative) with a comment on this issue, this would be most welcome. I promise to maintain your anonymity, as I understand that those working for a trust may feel there are pressures not to speak out freely, honestly. But without an honest look at the policies, without a sensible methodology, we are doomed to failure. If the emperor is wearing no clothes, what are we to do?

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Link to:

Independent article

Contract implementation guidance: Choice of named consultant-led team