GPs refusing to extend their practice boundaries, from Pulse

17/07/2012

Pulse has published an article on the resistance by GPs to extend their practice boundaries. I have posted the following comment to this article:

When a practice decides on its practice boundaries, it needs to be clear about the ecology of the practice’s functioning. What are the outer limits in allowing the practice to deliver good quality primary care, in an efficient, cost effective, and safe way? This should be the prime, and perhaps only, consideration.

GPs should resist firmly policies that undermine the ecology of good quality British general practice.

The policy to abolish GP practice boundaries is, when you scratch the surface, a hollow shell, an illusion, which will introduce all sorts of problems and give only a limited number of resourceful individuals ‘choice’.

If this policy was a financial product, it would be charged with gross mis-selling.

It is very important in the coming months that the GP community become more resolute and clear about this, and refuse to implement changes which will cause the service to malfunction. It is important that this issue becomes more public, and that mainstream journalists gain an understanding of how general practice functions. At present, they rely on press releases from the Department of Health’s media centre.

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For a series of posts on the stupidity of this policy, click here


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.


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

05/06/2012

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

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

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

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


8. How can they be so stupid? Duplicity

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.