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


13. How can they be so stupid? Corporate lobbying?

05/06/2012

I put a question mark after corporate lobbying simply because I have no direct proof myself of this activity. I am close to certain that this activity has taken place over time with respect to the issue of GP practice boundaries, and I think it is likely that this plays a central role in driving this policy. The politicians talk about patient choice, but underneath it all is really an aim to de-regulate English general practice and open it up in quite a new way to for profit companies.

How and why?

At present practices cover a limited geographical area. This limits the number of patients. Remove this factor, make registration free of geography, then it opens up an entirely different model which can be exploited by companies like Virgin Care.

These companies can set up medical centres in major cities, wherever is most profitable. They will attract a clientele of mobile, essentially healthy professional people. They will not have to deal with these patients when they are actually sick because they will be too unwell to travel to their centres; someone else will have to visit them. The elderly, people with chronic diseases, will remain registered with local GPs.

It will be convenient for the mobile and well, and profitable for the firms. But it will not deliver primary care in any real sense, and will in essence be a virtual asset stripping.


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


My comment to Tim Montgomerie’s post advising David Cameron to drop the Bill

10/02/2012

Tim Montgomerie, blogger at Conservative Home, advises David Cameron to drop the Health and Social Care Bill: click here.

 

My comment to his post:

I am a GP in Tower Hamlets and therefore one of the many who have to actually deliver the health care. What I want is policies that help me deliver good quality primary care to my patients. Unfortunately, the politicians and Department of Health have for some years dreamt up policies that make my job harder, if not actually impossible. The basic problem seems to be a shocking disconnect between the aspirations (increasing patient ‘choice’, ‘modernisation’, ‘reform’) and the reality on the ground. One particular example is the issue of GP practice boundaries: all 3 parties want to abolish them. At first glance, this seems like a good idea: choice, who does not want choice. But you then need to ask: are there any unintended consequences, are there any risks, how will it work, will it work? These questions are not asked. And yet, abolishing GP practice boundaries will not actually deliver patient choice; it will make provision of good quality primary care more difficult, less efficient, and at times unsafe; it will cost more money. (Of course, there is a hidden agenda in this: it will suit some vested interests to deregulate English general practice.) For more documentation on this, see my blog at http://www.onegpprotest.org
I am perfectly happy to work with others to find ways to reform things (as opposed to sabotaging them), to make things work better. But it must be done honestly, in good faith, and the nuts and bolts of earthly reality must be taken seriously. Otherwise we will view you with contempt. As the late physicist Richard Feynman said in another context, ‘For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.’

 


Andrew Lansley’s words to RCGP Conference 2011 on choice of GP practice: can we trust him?

31/12/2011

At the end of October, I watched the videos provided by GP Online of Andrew Lansley’s speech to the RCGP Conference, and his answers to questions from the audience. The speech is about 19 minutes long. A few minutes are given to the issue of choosing your GP practice, starting 11 minutes into the speech. Here is a transcription (my added emphasis):

…But I also want to talk about an aspect of choice no doubt many of you will regard as very controversial, that is choice of GP practice. The last government proposed giving people greater choice of GP practice, you’ll recall that; they initiated a public consultation and the public said they wanted choice. We also know the great majority of people will always want to choose a local GP practice.

Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this. But there is a small proportion of patients who feel that the current system just does not meet their needs. People who may have moved away, a short distance, but want to maintain their relationship with their current practice. People who find it difficult to see a GP because they are at work whenever their local practice is open to see them. Tackling inequalities means making services more responsive to everyone’s needs.

But the last government’s proposals on choice of GP practice didn’t take account of the practicalities of achieving that choice. We will ensure that any progress is practical, and we need to think carefully about how to manage home visiting, about how patients who don’t live locally to their practice can receive urgent care, and about how information is shared. And we will make sure it is done in a way that preserves the responsibility of Clinical Commissioning Groups for the health of their local population.

Now I want to ensure that we do respond to the needs and expectations of the public, but I want to do it a way that takes careful account of what is best for patients, particularly for the most vulnerable of patients, and in ways that are, in practice, effective.

*

There are a number of important points made in this part of his speech, and we will have to work hard to hold Lansley (and the other policy makers) to these. I say this because more and more I feel that Lansley is a slippery customer and that he ‘speaks with a forked tongue’. More and more I feel this drive to abolish practice boundaries is really just a scam, and the aim is really to deregulate general practice, and introduce a very different model of general practice. In his words to the RCGP Lansley says, ‘Now I’m clear that whatever we do general practice must always remain rooted in local communities.’ Yes, I would agree with that. But then this morning, I find an Associated Press release on the just announced pilots to allow patients in Manchester, Nottingham, and parts of London (including my own, Tower Hamlets) to register with ‘practices of their choice’. In this release, Lansley is quoted as saying, “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.” To my mind saying that ‘general practice must always remain rooted on local communities’ means that you will be, willy nilly, restricted by ‘geographical boundaries’: where you live is where you are. Until bodily translocation becomes possible, this will remain a constraint.

In his speech, Lansley mentioned two categories of patients whose needs needed to be met: those who move a short distance and wanted to maintain their relationship with their GP, and those whose work schedule means they cannot see their local GP. I think it is reasonable to try to find ways to meet these people’s needs. But the pilots seem to be for everyone, those wanting to register with a practice near their childrens’ school, and so on.

But perhaps the most important thing we need to hold Lansley to is this: he says the last government ‘didn’t take into account the practicalities of achieving that choice’; he is right in saying this: New Labour and the DoH did not look at the ‘practicalities’: indeed, they avoided the ‘practicalities’ almost entirely in the so-called ‘Consultation’. What Lansley does not say is that he himself was no better at thinking about the ‘practicalities’ when espousing this policy back in 2009 or 2010 (see my email exchange from March 2010).

I’m afraid that the words of ‘reassurance’ that Lansley delivered to the RCGP Conference were empty, designed to lull the audience into complacency.


Thoughts on the GPC-DoH Agreement on GP Practice Boundary Issue

13/11/2011

News reached us just under 2 weeks ago the GPC and Department of Health had reached an agreement about the issue of practice boundaries. There are two provisions: 1. practices will be encouraged to reach an agreement with their PCTs about an ‘outer’ practice boundary which will allow patients to remain registered should they move outside the ‘inner’ practice boundary, ‘where clinically appropriate’. 2. There will be two or three city pilots for commuter patients to register with a participating practice close to their work, and an independent evaluation will be carried out.

I have campaigned on this issue, having seen the orignal proposed policy (patients in England being able to register with the GP practice of their choice, ‘anywhere in England’) as quite mad and unworkable. I am pleased with this outcome, and the GPC is to be commended for having negoiated this. As should the GP body that resisted the proposal.

This current arrangement implicitly recognises that general practice is a local and community-based technology, which the previous proposal (which all 3 major parties subscribed to) ignored entirely. Even the commuters will need to register with a practice not far from their work.

Of course, there are significant practicalities which will need to be addressed: who pays for the costs of the commuters? How is this money transferred? How does this fit in with Clinical Commissioning  Groups and commissioning? Certain areas, such as the Isle of Dogs in Tower Hamlets which hosts Canary Wharf and a commuter population of about 100,00, will be affected very significantly. And then, what happens when the commuter is ill at home, how does he or she access local help, especially if the illness needs more than one GP encounter?

It is absolutely vital that the ‘independent evaluation organised by the Department [of Health]’ be truly independent and honest and rigorous (that is, not on the model of the so-called ‘consultation’ on this issue carried out by the DoH in March-July 2010 which was PR exercise which misled the respondents and Parliament).

It must be said that the inner and outer boundary model is something that some practices have had in place for many years already. Under the agreed provision, practices will have the option of having an ‘outer boundary’ and clearly they will have to choose a boundary that allows them to deliver a functioning service. That is well and good.

It is very important that the politicians and DoH do not attempt to resurrect this mad idea in the future, and that we make it clear to everyone that UK general practice is at its core a locally based technology which simply does not work on the same model as McDonald’s and mobile telephones. It may be possible to make exceptions in certain circumstances (such as the commuter), but this is an exception rather than the thin edge of the wedge.

A large wooden stake needs to be driven firmly into the heart of this vampire. That is why I will continue to write to MPs and continue to write about this issue because I have not covered all the ground yet.


Troubling Patients in Troubling Times: workshop at RCGP

04/11/2011

I’m just back from a day’s workshop at the Royal College of General Practitioners. The title: Troubling Patients in Troubling Times. This was a joint venture by the APP (Association for Psychoanalytic Psychotherapy in the NHS), The Balint Society, and the Royal College of General Practitioners. The participants were psychologists, psychotherapists, counsellors, GPs.

As is often the case with things named by psychotherapists, the title is a bit ambiguous, thought provoking. It was not about professionals troubling patients in troubling times, which is one possible reading. It was about, in part, patients troubled in these troubling times. Patients who bring their distress to the GP, the psychologist, the counsellor, the psychotherapist. ‘Troubling Times’: of course, this refers to the current context, with cuts in services, more pressure on the remaining services, with ‘reforms’ which are wolves clothed as lambs. But in some ways, all times are Troubling; but perhaps some more than others.

The introductory talk was given by Jan Wiener, a psychotherapist with many years experience of working in the primary care setting in partnership with GPs. Her talk, which I will not summarise, was entitled ‘Mindlessness in Troubled Times’. The title, I think, is enough to give pause for reflection.

We had a series of GP consultation vignettes, acted by the organising committee members which captured a wide variety of common primary care dilemmas and challenges. Some were troubling, some gave us to laugh.

Then small group work, a Balint group watched by the wider group, a small group Balint case discussion, and then a plenary session.

Many themes emerged. The ones I recall at this moment: with services being cut, there are people with significant distress who are then left without an important support; the importance of the work of psychologists/counsellors/psychotherapists; the central role of the GP; the importance of collaboration, communication; the (occasional, ? frequent) breakdown in communication between hospital and primary care; the mindlessness of some ‘reforms’, some protocols; a feeling of powerlessness in the face of the mindlessness (who do you take your concerns to? if your manager does not understand the work you do, what do you do?; and so on).

There was a sense that people had significant grievances which they needed to address to those in charge. I encouraged them to find out who these people were, to speak out, to protest. A few asked me about this blog. I gave them some advice about starting their own blogs. I wish them all the best.

One young GP voiced this: the bewilderment at the government asking us GPs to do things that make our job more difficult. Ah, yes, a familiar story.


An early morning email to Lib Dem MPs

15/09/2011

It’s me again, I’m afraid. I thought I better warn you about what almost certainly lies ahead with respect to the issue of GP practice boundaries.

I have never felt that this added up: from a practical point of view, it just does not make sense at all. I thought these politicians and DoH planners were just grotesquely stupid.

The reality is almost certainly one of deceipt and corruption, with the rest of politicians either complicit or just naïve.

A member of the public left a comment on my blog yesterday; he had joined up the dots, and at the end he mentioned the ‘virgin assura system of connected health centres across the UK’. I was unaware that such a thing existed. I had hypothesised that such a thing would exist in the future and that this was why they wanted to abolish GP proactice boundaries. But I woke this morning at 4am and thought I would just check, and, lo and behold, I found this.

I suggest you have a look at the leaflet that the DoH and New Labour produced  to accompany the so-called ‘Consultation’ on the question of GP boundaries in March 2010. Notice that nowhere in the leaflet, and nowhere in the larger consultation documentation, do they say: ‘and you could join the Virgin Assura system of connected health centres’, but this is in effect what the abolishing of GP practice boundaries will do. That is why they want to do it, otherwise it just does not make sense. All this talk of ‘patient choice’ is just camouflage. Just have a look at Virgin’s website, and then look at the DoH leaflet. The leaflet is a promotion of what Virgin is offering. And note that the proponents of this policy use the results of the ‘Consultation’ as evidence that the English public want this. But the ‘Consultation’ was pitched in such a way so as to produce this result, the questions are skewed in this direction.

There is really a lot more to this, and it will come out in the open in due course, I am sure. Because the media (who up to now have been crap about this issue, completely uninterested) is going to wake up soon and start shining a light on this.

Why am I writing to you at 4am? Because you people are heading off to your conference and you have been told by your leader that you cannot mention the NHS. And yet, shouldn’t you be talking about this?? Nick Clegg may have some sort of future as a Tory MP, but the Lib Dem party will have had it entirely when it becomes clear that you have been duped and used, along with the English public, as the NHS is swallowed up the the piranhas. Once they pass the law, there will be no going back.

I just thought I had better warn you.

And now I’ll have some breakfast, and then go to the surgery and see some patients, all of whom live local to the practice.

Best wishes,

George