On recognising and naming MOOspeak from @Dhgovuk & @DeptHealthPress

19/01/2014

The Department of Health is a large organisation, with different departments performing different tasks. No doubt, there are some departments carrying out noble and important work, and many of the civil servants working at the DH are, I am sure, dedicated to trying to make a positive difference to the provision of healthcare in the UK (or is it just England now?).

But there are some departments, the ones handling the more politicised policies, that are having to plan, promote, and implement policies that are not actually positive ones, and where there are significant unintended consequences. During the debate surrounding the Health and Social Care Bill many criticisms and misgivings were articulated. The Department of Health was then having to defend these policies and the methodology by which they were being planned, and this was most evident in the statements issued to journalists in response to the critiques.

‘A spokesman for the Department of Health said, ………’; ‘a spokeswoman for the Department of Health resplied…..’. These statements were understandably designed to minimise the damage done by the critique of the moment, but it meant that they were often fatuous and disingenuous. And what was frustrating from the point of view of those of us who work within the health economy was the, for the most part, the journalists just accepted these statements at face value, even if they contained falsehoods.

An example of this was when, in February 2012, 154 senior paediatricians (including 19 professors) wrote a letter to the Lancet to voice their concerns about the damage that would be done by the Bill. This naturally received attention in the press.

The Department of Health’s response, as quoted in this article:

A spokeswoman for the Department of Health said: “We have listened and substantially strengthened the Bill following the listening exercise. It’s not true to say that the Health and Social Care Bill will fragment children’s healthcare. In fact, the Bill will help address the very concerns about fragmentation that the experts raise. It will help the NHS and other public services work together better for children, young people and their families. These 150 individuals represent just over 1% of the total members of the Royal College of Paediatricians and Children’s Health and cannot be taken as an accurate representation of the College, who we continue to work with.”

The template for these responses is seems to be something like this:

a) make a positive-sounding statement (‘we have listened and substantially strengthened the Bill’); b) refute the criticism (without responding to the substance of the criticism); c) make some positive-sounding noises about the policy (the Bill ‘will help the NHS and other public services…’; and, sometimes, d) undermine the credibility of those voicing the concerns (as in this case).

What struck me about this example at the time (and why I kept the links) was that some anonymous spokeswoman at the Department of Health (who almost certainly had no experience working in paediatrics or medicine and was in all likelihood a PR person) was implicitly afforded equal status in this debate. So we had some paediatricians saying one thing, countered by the (unsubstantiated) assertions of a ‘spokeswoman’ without any qualitifications. Paediatricians 1, Department of Health 1.

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What we need is a basic analysis of these communications from the Department of Health, a deconstruction. And where the DH statements are dishonest, disingenuous, misleading, and just meaningless spin, they should be named and ‘outed’ in an efficient way.

For the moment, I am going to use the term ‘MOOspeak’, but I would be happy for any suggestions for a better term. Remember, it needs to be short so able to be used on Twitter.

I would suggest that if a journalist feels the the statement they receive qualifies as MOOspeak, that they write something like:

A spokeswoman from the the Department of Health, issued this MOOspeak statement: ‘Blah blah, etc…’

Or: A MOOspokesman for the Department of Health said, ‘Blah blah….’

Or: In a statement from the Department of Health, which sounded awfully like MOOspeak, …..

I think they would issue fewer MOOspeak statements and we would have a more honest discussion.

And then, perhaps, we could move on to politicians and their ‘speak’….


My warning to Jeremy Hunt on the dangers of abolishing GP practice boundaries, 3rd attempt

11/01/2014

Dear Jeremy Hunt,

I sent you emails on 8/9/13 and 13/10/13 warning you about the problems associated with a Coalition Government proposed policy. Consider these ‘complaints’, ‘whistleblowing’. The replies I have received do not in any way address the concerns I raise. You have said that hospitals need to address complaints transparently and be responsive to members of the public, that problems should not be hidden. You have said that staff who neglect patients’ safety should be liable to criminal prosecution.

So far you have evaded the issues I have raised in my previous emails. I am saying that this policy is unworkable, that in some cases it is unsafe; overall, it will impact negatively on the functioning of general practice. If harm comes to patients because of this policy and you and others have wilfully neglected a proper risk assessment, will you be accountable?

I require the following by way of response:

A. I challenge you and your officials at the Department of Health to respond, point by point, to my submission to the Health Select Committee.

B. In the Department of Health’s media launch of the so-called ‘pilot’ in December 2011, we read: “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.”

This detail of families registering at a practice near their children’s school is repeated in the evaluation Proposal submitted by Professor Mays in May 2012.

So you think this is a good idea? I challenge you and your associates at the Department of Health to answer the following questions about this particular idea:

1. What benefit accrues to a family if they register with a practice near their children’s school? Why would they want to do it?

2. How would this work practically? (Details please, full details of the mechanics of this).

3. Are there any risks or problems with this proposal?

Perhaps journalists can have a go answering these questions; and Andy Burnham; and Stephen Dorrell and his colleagues on the Health Select Committee.

Come on, have a go. Let’s see if the emperor is wearing any clothes.

Yours sincerely,

George Farrelly, GP

The Tredegar Practice
35 St Stephens Road
London
E3  5JD

Resident in London N7


My concerns about the ‘independent evaluation’ of the choose your GP practice pilot

11/01/2014

I have written to the current Secretary of State for Health, Jeremy Hunt, about my concerns about the proposed policy to abolish GP geographical boundaries. To my first email, I received a non-reply masquerading as a reply and so I sent a second email. The reply to this second email was no better than the first and in fact covered much the same ground as the first reply. So I have emailed him again today. (I have sent similar emails to NHS England and the CQC; NHS England’s reply was wholly inadequate so I have written to them again).

The replies I have received so far have limited themselves to describing the structure and process of the Pilot (which ran from April 2012 to April 2013), and the fact that an ‘independent evaluation’ would be made, and sent to the relevant bodies, including the GPC and NHS England (who have inherited the responsibility for implementing (or not) this policy).

I have been sceptical about this policy from the beginning, and my scepticism has if anything grown over time. The policy sounds attractive at first sight, but to anyone who knows how general practice in the UK works (its ecology), the policy does not make sense. The Department of Health so far have promoted this policy assiduously, ignoring the problems and risks. The 2010 ‘consultation’ was a PR exercise, structured in such a way so as to get the desired result, a New Labour ‘dodgy dossier’. The politicians and Department of Health have since used the ‘results’ of this rigged consultation to continue to push for this policy.

The Pilot structure did not actually test the policy itself in any true sense. I wondered how the evaluation would be structured: I thought it likely that it would avoid evaluating the policy itself.

I contacted Professor Nicholas Mays of The London School of Hygiene and Tropical Medicine, and Director of the Policy Research Unit in Policy Innovation Research who were commissioned to carry out the evaluation. I asked Professor Mays if I could see the ‘spec’ the Department of Health had sent them; he did not have such a document, but sent me the Evaluation of GP practice choice pilots, Proposal, 14 May 12 that he had submitted to the Department of Health in response to their request. He suggested I contact the Department of Health about the specification and so on. What I found out was that the Proposal was the result of a meeting between Department of Health officials (I do not know how many) and Professor Mays (I do not know if other members of the Policy Research Unit were present). The Pilot was discussed at this meeting, and the Proposal resulted from this discussion. The meeting was not minuted. So no written ‘spec’.

I read through the Proposal and it confirmed my fears. The evaluation was designed to assess the Pilot rather than the policy. This sentence is from the first paragraph, under the heading ‘Rationale’:

“According to the Department of Health, 75% of patients who responded to a recent consultation on GP choice made it clear that they wanted greater ability to register with a practice of their choice irrespective of its location.”

This is the ‘consultation’ which I say is rigged. Has Professor Mays read the consultation documents and assessed how this ‘75% of patients’ was engineered?

Further along in the Rationale section is the following:

“People able to access GP services in the pilot areas will have greater choice and flexibility about the GP practice that provides their personal care. It will mean patients are able to register close to work, close to a relative they care for or even close to a child’s school.”

This detail, ‘even close to a child’s school’, bears further scrutiny. It was one of the avowed benefits of the pilot (and therefore the policy) in the Department of Health’s media launch in December 2011. I wonder if the evaluation will scrutinise this detail. Will it ask if this detail, registering with a practice near a child’s school, actually makes sense? What benefit accrues from this? How does it work? Are there any risks? Did Professor Mays’ team ask these questions, or did they just take this as a given?

I replied to Professor Mays as follows (19/10/13):

“I have now read through your Proposal for the Evaluation of GP practice choice pilots. It confirms what I feared. Your evaluation does not actually scrutinise the policy itself. I am not criticising you or your team but I think the DH has given you a brief which means that you avoid asking some very basic questions. I am sure that you have done good, thorough work, and I am sure you will come up with some interesting and useful insights; but it is likely that your ‘evaluation’ will miss the basic, fundamental flaws of this policy. These flaws are not exposed, revealed, by the ‘pilot’.

I attach my Submission the the Health Select Committee of May 2013. It outlines what I see as the main problems, I hope in a clear way. I suggest you and your team read this document.

What I am saying is that this policy has been promoted without taking into account the problems, the side effects, the unintended consequences, and it would appear that this has been done intentionally, wilfully. When thalidomide was launched in the late 50’s, it was marketed as a wonder drug, and there were real benefits. But there were also very considerable problems, which emerged with time.

Your evaluation will, by its very design, concentrate on the benefits of thalidomide, the marketing and distribution strategies of thalidomide, but not with the unwanted side effects.

I know what the problems are with this policy, I deal with them on a daily basis, and what I have outlined in my Submission is just the tip of a large iceberg.

I would be happy to meet with you to discuss this further, if you think that would be constructive. I am copying this to the GPC.”

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I have not yet been able to see the final report that was sent to NHS England and the GPC. Professor Mays has told me it is being peer reviewed and then will be available, perhaps in the next month or so. Once I have read it, I hope then to meet with Professor Mays to discuss this further.


My complaint to NHS England about abolishing GP boundaries, second attempt

15/12/2013

Dear NHS England,

On 10 September 2013 I sent you a complaint, and have received your reply (see below).

I do not feel that this reply in any way addresses the substance of my complaint [my complaint was a copy of my first email to Jeremy Hunt]. The reply is largely a description of the structure of the choice of GP practice pilot. Whilst I did mention this pilot in my complaint, the substance of the complaint relates to the policy that the pilot is allegedly testing. I have criticisms of the pilot itself, but these are just part of an overall critique.

You mention the evaluation of the pilot carried out by Professor Nicholas Mays and his team. I have been in touch with Professor Mays and have seen his Proposal regarding the evaluation (but not the report which I am told is confidential). The scope of the evaluation does not include an evaluation of the policy itself; the rationale of the evaluation contains some quite questionable assumptions. I will return to this at another time [click here for my post on this issue]. I hope I will be able to see the report.

I would like you to try again with my complaint. I would suggest that you read my Submission to the Health Select Committee (reference number 5 in my email to Jeremy Hunt below; I am attaching it as a document to this email).

In summary, my complaint is as follows:

1. Good quality British general practice is a complex technology which delivers service to a local population. Its ecology is a local one. In our experience, people who move away and live at a distance from the practice receive poorer care; moreover, attempts to deliver care to people who live at a distance is inefficient, and at times unsafe. Distance is a barrier to care.

2. Much of what we do on a daily basis works because it is local. Were it not local, it would not work.

3. There is then an added problem, that of capacity. Our practice is unable to register all the patients who want to register with us from within a relatively small practice area. We are currently working beyond our capacity, and this drives down the quality of our service in terms of access and the time we can spend with patients, especially those with complex needs. We are not alone in this: almost all practices are working beyond their capacity limit. They simply will not have the space to look after additional patients (who would then bring with them the added problems of living at a distance from the practice mentioned above).

4. The politicians who have promoted this policy have simply ignored what I have outline in nos. 1-3 above. They have not undertaken an honest risk assessment.

5. Worse still, the Department of Health has not undertaken an honest risk assessment. They too have presented this policy in an idealised ‘rose tinted’ way, glossing over the very real problems inherent in a geography-free model. I am saying that they have been very misleading and dishonest.

So I would ask for a robust response to the issues I am raising, not written by some ‘customer relations’ worker who clearly does not have an understanding of the issues.

1. Please deal with the issue of distance from the practice. Does NHS England understand the risks of distance from the practice? (see my submission to the Health Select Committee, with back up documentation in the form of references).

2. Please respond to the issue of capacity. (Again, see my Submission to the Health Select Committee).

3. The Department of Health mentioned the ability for a child to be registered with a GP practice near his/her school (in the press release of December 2011 announcing the pilot, and it appears again in Professor Mays’ Proposal, as one of the rationales for the policy). Can you please tell me a. what benefit accrues to a child and parents with such an arrangement?; b. how would this work from a practical point of view? (yes, please spell it out); c. what are the possible risks or problems with this arrangement?

4. Please respond to the problems with visiting patients who are not registered with a local practice. Again, see the relevant paragraph in my Submission to the Health Select Committee.

Many thanks for your help.

Yours faithfully,

George Farrelly
The Tredegar Practice
35 St Stephens Road
London
E3 5JD

[26/8/14: The above was sent to NHS England in December 2013; I have received no reply at all.]

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Reply from NHS England 26/11/13

Dear Dr Farrelly,

Re: Complaint reference SDR136238

Thank you for your e-mail of the 10th September 2013 raising your concerns regarding the choice of GP practice pilots.

I have been in touch with the GP contracting team in the NHS England Commissioning Development directorate who have provided me with some expert advice on this matter in order to enable me to provide you with an appropriate response to your concerns.

As you will know In April 2012, the Department of Health agreed a 12 month variation to general practice contracts giving patients a right to choose to register with any GP practice participating in the pilot without being restricted by the practice boundaries previously agreed with Primary Care Trusts. The pilot allowed patients to access GP practices beyond the areas in which they lived, in four participating PCTs (Westminster, Salford, Manchester and Nottingham City). It was expected that the pilot would benefit patients by giving them more freedom, choice and control over where they accessed care. It also included an option for patients to be seen as ‘day patients’ without registering.

The pilot scheme operated until the end of March 2013 although patients who have registered with a participating practice have been able to remain with that practice while the scheme is being evaluated in order to ensure that continuity of care is provided.

The scheme is being evaluated by the Policy Innovation Research Unit at the London School of Hygiene and Tropical Medicine and their final report is due during November 2013. Any proposals for changes to the GP contract to extend patient choice following consideration of the evaluation report would be need to be discussed with the BMA’s General Practitioners’ Committee.

We are anticipating that any issues relating to home visiting and access to community services will be highlighted from the evaluation and can then be addressed while considering the evaluation in its entirety.

I hope that this has answered your questions with regards to this matter. If you have any further concerns or questions relating to this matter please do not hesitate to contact us at england.contactus@nhs.net, or by calling 0300 3 11 22 33. Please do not reply directly to this email.

Yours sincerely,

Jane Doe (name changed to protect the innocent)

Customer Contact Centre Case Officer
NHS England
PO Box 16738, Redditch, B97 9PT
0300 3 11 22 33


I smell a rat. Is Monitor working in the interests of patients or free market healthcare?

27/10/2013

I recently set up a Google news alert for articles on GP practice boundaries.

It threw this article up this morning.

“Monitor senior policy adviser Paul Dinkin, the man heading its primary care consultation, said his initial conclusion was that Monitor would play a major part in primary care.”

“Mr Dinkin said his review was looking at barriers to entry into general practice, such as practice boundaries and registered lists.”

“He said the BMA and the RCGP were wrong to say general practice needed more funding. ‘Our suspicion is not more money for the current model, but to rethink who does what.'”

And my suspicion is that Mr Dinkin does not know a great deal about the ecology of general practice, and that he has little interest in finding out.

Checking on the Monitor website, I found a Call for evidence on general practice services sector in England.  Issued on 1 July 2013, deadline for responses 1 August 2013. So I won’t be offering my views.

Who is Paul Dinkin and what is his background? I could find precious little online. Even on Monitor’s website there is no information.

Can we have some transparency, please?


My email to Stephen Dorrell, Chairman of Health Select Committee, on GP practice boundaries

20/10/2013

Dear Stephen Dorrell,

I sent a submission to the Health Select Committee in May 2013 raising concerns about the Government proposal to abolish GP practice boundaries (1).

A concluding paragraph read as follows:

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.

I sent an email to Jeremy Hunt on 8/9/13 raising my concerns (copied to you) (2); in response I received an evasive and irrelevant reply from the Department of Health (3); I sent a second email to Jeremy Hunt a week ago (again, copied to you) (4).

You were contacted by Pulse following my submission in May (5), and the article suggested that the Health Select Committee were going to investigate the policy. Has it done so? If yes, why was I not called to elaborate on, and to substantiate, my charges? If you have not investigated this matter, do you intend to and when? If you do not intend to examine it, why not?

I am aware that there is a glaring conflict of interest here, both for you personally and for your entire committee. Were you to investigate this policy, it would be very difficult to avoid coming to the conclusion that at best those involved in the planning and promotion of the policy were naive and ignorant and grotesquely incompetent (in short, a ‘blunder’); but, worst still, you might be unable to avoid concluding (as I have) that there has been a wilful misleading of the public and of parliament, that it is not just a blunder but actually a scam, a fraud. This would be embarrassing for your party as this, remarkably, appears to be a flagship policy for the Government (6),  and embarrassing for the Labour Party (one of the prime promoters of this policy was Andy Burnham when he was Secretary of State for Health; he is now the shadow minister for health and his credibility would be severely damaged if a light were shone on his involvement). So I expect you will do all you can to avoid looking at this honestly and fully. And that in itself will raise further questions.

If your committee is unable to scrutinise this policy thoroughly, then who should?

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD

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16/11/13: Yesterday it was announced that GP practice boundaries would be abolished as part of the new GP Contract. I have not heard from Stephen Dorrell or any member of the Health Select Committee. 

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26/7/14: I never received a reply to this email which was copied to all members of the Health Select Committee

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1. My Submission to the Health Select Committee

2. My email to Jeremy Hunt, 8/9/13

3. Response from the Department of Health

4. Second email to Jeremy Hunt

5. Pulse article 10/5/13

6. Coalition Government claim that the ‘pilot’ is evidence that they have improved the NHS


My Submission to the Health Select Committee on GP practice boundaries

19/10/2013

[I sent this Submission to the Health Select Committee in May 2013. I have not heard from them.]

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Submission by Dr George A. Farrelly, General Practitioner, regarding the Government policy intending to abolish GP practice boundaries. This submission is made in a personal capacity, though I believe I represent the views of many GP colleagues.

Summary:

  • The Government and Department of Health wish to abolish GP practice boundaries, saying that it will increase patient choice, drive up quality, and remove anachronistic constraints.
  • From my perspective as a GP with 25 years’ experience of trying to provide good quality general practice to a local community, this policy may sound attractive on the surface, but in reality will simply not work and will cause general practice to malfunction; in some cases it will be unsafe.
  • The Government and Department of Health are either remarkably stupid, or they have a hidden agenda and are engaged in an elaborate deception.

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1. I am a GP in Tower Hamlets. My wife and I have run a small practice in Bow for 22 years (I had worked in Islington before that). The practice has grown, and we have two part-time salaried GPs and a GP registrar. Our aim has always been to provide good quality, evidence-based family medicine with a human touch. We are part of a local network of 5 practices in Bow (practices in Tower Hamlets are all part of a Network; there are 8 Networks). We are a training practice; we teach medical students.

Before studying medicine at St Bartholomew’s Hospital Medical College, I did an undergraduate degree in history (Harvard University, Magna cum laude), and a postgraduate degree in International Relations (LSE, MSc, Distinction).

In addition to my core job as a GP, I was Medical Director of the Tower Hamlets Out of Hours GP Co-Operative from 1997 to 2004. THEDOC, as it was called, provided out of hours GP cover for the Tower Hamlets population.

I feel very fortunate and privileged to be working as a GP. I feel very fortunate to be working in Tower Hamlets which has a tradition of committed GPs working collaboratively to provide good quality primary care for our population, and we have had the support of a forward-thinking PCT.

Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

2. As GPs we serve a local community. Over the years, in our practice, we have had much experience looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney, and who have wanted to remain registered with us.

We have found that living at a distance from the practice creates a barrier to care. We have found that these patients tend to delay being seen; that it is more difficult and time-consuming to manage their illnesses; sometimes they are too ill to travel to see us, and we are unable to visit them. At times it is unsafe.

As a result, we are firm with patients who move out of our practice area and ask them to register with a local GP.

And so when in 2009 politicians began to say that they wished to abolish practice boundaries, we were bewildered.

3. There are two main reasons why this proposal makes no sense:

a. first, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; this becomes increasingly significant in proportion to the severity of the patient’s health problems. (1)

b. two, because GPs are all currently working at full capacity (indeed, in some cases, beyond their capacity). The ‘good’ practices are already ‘full’ and cannot accommodate a significant increase in demand. There is a risk that ‘outliers’ will take the place of local residents, or impact negatively on the services of local residents (further discuss in paragraph 5 below).

So there is a very serious design fault at the heart of this policy. For over two years I have been attempting to draw attention to the problems inherent in this policy by blogging, writing to MPs, and to journalists. Last Autumn I wrote 6 articles for the GP publication Pulse on this issue (2). And I published these articles on a separate self-contained blog. (3)

4. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But the replies I received from the Department of Health simply did not make sense. (4) And so over time I have gradually come to the view that the evidence (evidence that is in the public domain) points towards a more disturbing process at work: that there is a hidden agenda behind this policy. My hypothesis is that the real aim here is to de-regulate general practice. At present, because it is geographically defined, it limits the type of business model that can be used to gain access to general practice. By removing the geographical element in primary care, you change significantly the business models and frameworks that can be applied.

But in order to abolish GP practice geographical boundaries, it has been necessary to create a pretext, or a series of pretexts. A narrative has been created and it has these elements: most people are happy with their GP; but some are not, and they should be able to have choice; GP practice boundaries constrain choice, they are old fashioned, anachronistic; there are a number of reasons why patients might want choice: to have a GP close to work, to register with a GP near their child’s school, to remain registered with their trusted GP should they move away; there might be a GP skilled in a disease in a practice outside their area; the only thing that is needed to make it all work is to sort out how visits will be done should the patient need one.

What this narrative leaves out are the two areas mentioned in paragraph 3 above: the systemic problems of patients living at a distance from their GP, and the problem of capacity. It also fails to mention the problems inherent in providing visits for people registered at a distance from their practice (see paragraph 9 below).

5. Some additional notes on the issue of capacity.

a. In our practice we have struggled with this. Because we are popular, people have wanted to register with us. This has driven us to a list size beyond our capacity which has a negative impact on the quality of the service we provide for our patients, and we have a workload which is unsustainable. The only way we have had to cope with this was to shrink our practice area further a few months ago. So there is no way we could cope with an additional influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised in 2010); we are drowning as it is.

b. I came across an example recently which illustrates this problem quite eloquently. There is a practice in Kentish Town with a long established reputation; just the sort of practice that people for several miles around might want to join (if I did not know better, I would consider joining as they are less than 2 miles from where I live). If you go to their practice website you will see the issues they are wrestling with as raised by their patient representation group: they are having trouble providing access to their own patients to the GP of their choice. And those are their currently registered patients, all of whom reside within their practice boundary. (5)

c. Another example illustrates this in a farcical way. The Department of Health chose City and Hackney PCT as one of their pilot sites. The City of London is served by one practice, which has a list size of under 10,000. As it happens, the City of London Corporation and NHS Northeast London had commissioned a study into the practicalities of providing primary care services to the commuter population of the City and this was published. The conclusion was that something like 120,000 of the 360,000 commuters were likely to want to register with a GP practice in the City, which would require 50 more GPs, and additional practice nurses and infrastructure (6). So there was really no way that the sole City practice was going to be able to cater to commuters interested in taking part in the pilot.

6. Andy Burnham, then Secretary of State for Health, went to The King’s Fund in September 2009; in his speech he announced his Government’s intention to abolish GP boundaries within a year. He said this move would make a ‘good’ NHS ‘great’ (at least this is what the press reported; I have asked the DH to show me the press release for this occasion; thus far they have been unable to produce it). But what he said about this in his speech really amounted to nothing, it was meaningless to anyone who understands how general practice works (and does not work). (7)

7. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice was launched in March 2010. If you look at this ‘consultation’ with a critical eye it is clear that it steered the readers towards responding in certain ways to the questionnaire. It used the narrative outlined in paragraph 4 above.

When it published the results of the consultation, the DH claimed it showed that the public backed the idea of choosing your GP practice and doing away with practice boundaries. Of course it showed that, it was designed to show that. Had they been honest about the reality of general practice, the respondents would have said: given what you have told us, why are you even proposing this policy? (8)

8. The Department of Health agreed with the GPC to hold a pilot around this policy. (9) The pilot is in progress. The present Government went so far as to say, in their Mid-Term Review, that this pilot was evidence that the Government had improved the NHS. “We have improved the NHS by …..—allowing patients in six trial primary care trusts to register with a GP practice of their choice.” (10) What the report omitted to say was that GPs in two of the six PCT areas opted to boycott the pilot because of concerns of the impact on resources of the local health economy (one of the many problems inherent in this policy).(11) What they also failed to say was that out of a possible 345 practices in the pilot areas, only 42 practices had opted into the pilot, and that as of the beginning of the 2013, only 514 patients had registered with a practice under the scheme. (12)

This ‘pilot’ in no true sense tests this policy. The Government and DH say that there will be an independent evaluation of the pilot. Given their behaviour so far, my concern is that the ‘evaluation’ will somehow avoid scrutinising the policy itself, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

9. The problem of visiting. People on all sides of the debate have acknowledged that the issue of visits would need to be addressed. But what most people have failed to grasp is the magnitude and breadth of this issue. At present, all patients are visited by their own GPs within working hours (8am to 6pm [or is it 6:30?]), Monday to Friday. And if the call is outside these hours, then there is a local arrangement for how these visits are covered. There have been problems with out of hours provision, with some high profile cases where patients have died due to not being assessed properly.

If this policy is enacted, then every area in England will require a structure to provide care for those who live at a distance from their registered GP. This provision will have to cover not only the out of hours time slots, but will of necessity be 24 hours a day, 7 days a week (because they will not have the cover of ‘their’ GP during working hours).

It is also important to understand that when a patient is seen out of hours, the notes from the encounter are sent to the registered GP. Almost always the notes contain a message that says something like this: ‘If not improving, for review by own GP.’ The trouble with the boundary free model is that there will be no local GP to manage the patient while unwell during working hours and at home. The out of hours service does not provide continuity of care, and does not arrange further investigation and referral where this is warranted.

10. There are a number of issues I have not mentioned in this submission, and this is by no means a complete critique of the proposed policy.

11. I think there is a case for finding a way to make good quality primary care accessible to people who work long hours at some distance from their homes. But the people designing a solution would have to adopt a sound methodology which would include honesty, common sense, and truly taking into account the ecology and practicalities of general practice.

12. Normally, if politicians or Government departments make unrealistic promises the media often provides a valuable corrective by scrutinising and challenging the claims. In the case of this policy, however, mainstream media have failed in this role, I think mainly due to ignorance of how general practice works. There have been three main waves of (limited) airing of the GP boundary issue in mainstream media: at the time of Burnham’s visit to the King’s Fund in September 2009, the launch of the Consultation in March 2010, and the press launch on 30/12/11. The mainstream press articles which appeared on those occasions essentially took the claims of the Department of Health (often misleading) and merely repeated them, as though they were ‘true’ and based in reality. (13) The mainstream press may at some stage wake up and review this issue.

13. 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.

14. I am writing as what some might call a ‘whistleblower’. That a busy GP, in a private capacity, should have to spend all this time in trying to get this message through to the politicians and those handling the levers of power seems to indicate that something is wrong. I am writing in the hope that you will listen and scrutinise this policy.

I am also writing so at least at a future date, should the policy be implemented and  the inevitable problems surface, politicians and the Department of Health will not be able to say ‘Nobody warned us.’

 

George Farrelly

The Tredegar Practice
35 St Stephens Road
London E3 5JD


1. For an article which illustrates aspects of the problem, see an article by an inner city GP ; for some examples from our own practice.

5. Difficulties of a high quality practice providing access for their patients. This is a very common problem; essentially, most practices are looking after too many patients. This is a capacity issue.


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.


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.

*

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

*

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.


My warning to Jeremy Hunt on policy to abolish GP boundaries: is it fraudulent?

07/09/2013

Dear Jeremy Hunt,

I am a GP in Tower Hamlets. I am writing to draw your attention to a policy which your government supports (as did the previous Labour government): the proposal to abolish GP geographical boundaries and to allow (encourage) patients to join practices at a variable distance from their homes. This patient ‘choice’ appears on the surface to be a welcome development. But as someone who has worked as a GP for over 25 years, it simply does not work: looking after patients at a distance from the practice introduces barriers to care; it is inefficient; it drains resources; it is at times unsafe. Moreover, it undermines the service to local residents. And this is just the tip of a very large iceberg.

Andy Burnham, when he was Secretary of State for Health, claimed that abolishing GP practice boundaries would transform the NHS from ‘good’ to ‘great’. To me this is a remarkably stupid statement.

And your government, in its Mid-Term Interim Review The Coalition: together in the national interest, refers to a pilot allegedly set up to test this policy as one of three examples of how the Coalition has improved the NHS:

“We have improved the NHS by: ….-allowing patients in six trial primary care trusts to register or receive a consultation with a GP practice of their choice.”

This sentence is wrong on a number of counts. The pilot in question allows patients in England to register with a  participating GP practice in one of six PCTs: the number of practices participating in this pilot is small (42 practices out of a possible 345 practices, or 12%). And the number of PCTs is in fact four because two of the PCT areas have boycotted the pilot due to concerns that it would be a drain on resources for local residents.

Perhaps as Secretary of State for Health you should find out why 2 PCT areas have boycotted the pilot, and why such a small number of GPs have agreed to take part in the pilot.

I have written to the Health Select Committee about this and you can access my submission here. I have published articles about this in Pulse (access here) and in a separate blog.

I have been following this issue for four years now. At first I thought the politicians and Department of Health were just remarkably stupid; but then I realised that the more likely explanation is that behind this policy was actually a financial one, profit for someone. And indeed it is organisations like Virgin Care who stand to gain from this policy, not patients, not primary care services.

And this is troubling because people say that you are a friend of these organisations. Is this true?

I will close with a quote from my submission 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.

Yours sincerely,

George Farrelly

The Tredegar Practice
35 St Stephens Road
London
E3 5JD