NHS 111: If they tried, could they make the communication worse?

27/07/2013

We recently received a communication from NHS 111 about a telephone encounter with one of our patients.

I have removed any identifying details, and I suggest you read it. This is supposed to let us, his GPs, know about the conversation.

If this were a parody, we would say it was over the top.

I actually spoke with this patient soon after this NHS 111 conversation. She/he was on a phone list, waiting for me to return her/his call. She/he had rung NHS 111 to ask the significance of a blood result. It would have been wiser just to wait for me to ring to discuss the result.

That this national programme should have planned for such a shockingly opaque format for communications is very very worrying.

Whoever you are, please go back to the drawing board.


Are GPs too lazy?

02/06/2013

Two evenings ago, when I arrived home at 9pm for supper, my daughter, with a smile on her face, pointed me to the front cover of the current edition of The Week which asks Are GPs too lazy?’ She and her brother were always clear that they were not going to study medicine because they thought their parents, both GPs, worked too hard.

I wish journalists were more precise in their use of language. Why not ask, ‘Are some GPs too lazy?’ Why not find out what it is like for a significant number of GPs?

It is 9am on Sunday morning and I am at work, trying to catch up on my mountain of work. I arrive at work at 7am weekdays, and leave on an early night at 8, other nights at 9. And I will not have finished. I work at least one day of every weekend. It is unsustainable. I will be 60 years old in 3 weeks. In our practice we try to provide good quality, evidence-based medicine in a respectful and compassionate way. But it is a real struggle. I would like to work on until I am 65. I have a sense of commitment to our population, I am aware that the role that I play is an important one.

Ultimately, there is a real problem with capacity. The demand outstrips the resources.

We have 10 minute consultations. Many of our patients require 15 minutes, some longer. The job I do now is far more complex than it was 15 years ago, it requires more time.

Yes, it is a bit of a slog for some to get appointments at times that suit their schedules. I am not happy about that.

The politicians and Department of Health set us Herculean tasks which undermine quality.

Politicians, journalists, citizens: be careful, if you blame us and ‘shame’ us in a mindless way, a significant number of us will just give up, and leave you to get on with it on your own. Let Jeremy Hunt do it; let the Department of Health spokesperson do it; let Janet Street-Porter do it.

If you want a better system, let people who understand the complexity of primary care design it and cost it. Then resource it.


Why GPs have practice boundaries

11/05/2013

[The following is an article published in BMA News, January 14, 2012, by Flora Tristan. It is no longer accessible online, so I am making it available here.]

We’ve been expecting this.

It’s Monday morning, I’m on call, and we are — as usual — a touch light on doctors. One colleague is consulting in addition to me, and a locum is booked to come in at 11am, though it’s not clear yet whether he will do any visits or scripts. At 8.50am a call for an immediate visit comes through, and it is all I can do not to say ‘I told you so’.

I establish that Alfie’s dyspnoea is not such as to justify a blue-light ambulance but is too serious to wait till later in the morning. My colleague assures me that she can deal with her surgery, probably the bulk of my surgery, phone calls, enquiries, immediate scripts, immediate collapses in the waiting room and immediate everything else, and I head out into the freezing sleet.

It takes me 40 minutes to get to Alfie. Partly, this is because I have to negotiate a road junction that is so notorious that it has frequently been a topic for debate in Parliament. But the main reason is because Alfie lives absolutely miles outside the practice area, and has done so for years. I pass five surgeries on my way, including the excellent practice opposite Alfie’s house.

When I get there, Alfie is in extremis with an exacerbation of COPD, and his daughter, Jane, who has learning difficulties and asthma, is crying.

‘He didn’t want to call you — said it was too far for you to come, doctor,’ she says. I wait with Alfie, and encourage him to use his oxygen while the ambulance comes. Then I get on to social services to arrange Jane’s care for the next few days. By the time I get back to the practice there are two complaints pending, 14 people are still to be seen, and my normally serene colleague is close to tears.

This morning was always going to happen. This is why I have been pushing and pushing in meetings for us to encourage Alfie and Jane to register locally. Not only has a single visit seriously impaired the care we can offer to other patients this morning, never mind causing substantial stress; Alfie’s care has also been affected by the distance he lives from the surgery, since he has been reluctant to call when he should have done so.

Today I am really not interested in the sentimental view of one colleague that Alfie should stay on our list as he has been with us for so long and he is frail. That is exactly why he would be better off with the practice across the road from his home. Nor am I inclined to ‘be flexible’, as the health authority suggests; it is only worried about the local press. We have practice boundaries for a reason, and this morning is it.

Flora Tristan is an inner-city GP


Warning to Health Select Committee on a policy damaging to general practice, from a whistleblower

06/05/2013

I wrote to you several months ago to check if you would be the appropriate body to deal with my concerns about a Government health policy. Two of your members kindly responded and said that it did seem appropriate for your committee. So I am now writing to ask you to look into the Government proposal to abolish GP practice boundaries.

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.

*

1. Who am I and why am I campaigning against this policy? I am a GP in Tower Hamlets. I have worked in our practice for 22 years. I was the medical director of the Tower Hamlets out of hours GP co-operative from 1997 to 2004.

I feel very fortunate and privileged to be working as a GP. Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

As GPs we serve a local community. Over the years, in our practice, we have had lots of experience of looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney. 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. (Examples provided in links, see below).

So we are firm with patients about registering with a local GP.

When in 2009 politicians began to say that they wished to abolish practice boundaries, I was bewildered.

2. There are two main reasons why this proposal makes no sense: one, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; two, because GPs are all currently working at full 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.

So there is a very serious design fault at the heart of this policy. For the past 2 years I have been blogging, and writing to MPs, to Ministers, to journalists to draw attention to the problems inherent in this policy.

Last Autumn I wrote 6 articles for Pulse on this issue.

These articles are also published on a separate blog.

3. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But I now think 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 (2) 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 below).

4. 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 this). 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).

5. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice, 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 (3).

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?

6. The DH agreed with the GPC to hold a pilot around this policy. 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.” 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). What they also failed to say was that 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.

This ‘pilot’ in no true way tests the 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, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

7. 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.

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.

8. 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.

9. 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.

10. I am writing as what some might call a ‘whistleblower’. That a busy GP should have to spend all this time in trying to get this message through to the politicians seems to me absurd. I am writing in the hope that you will listen and scrutinise this policy. But I am aware that there are many reasons why you as a committee might wish avoid this.

I am also writing so at least at a future date, when the inevitable problems surface, that you will not be able to say ‘Nobody warned us.’

 

Yours sincerely,

George Farrelly

 

The Tredegar Practice 35 St Stephens Road London E3 5JD

 

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Backing documentation

(Numbering corresponds to the paragraph numbering above)

2.. Looking after patients at a distance from the practice does not work and it at times dangerous:

Blog posts by me.

3. a. The narrative: the mainstream press has so far largely just reproduced what the Department of Health Mediacentre have told them in the form of press releases. There have been three main press releases, and corresponding articles in various media. Analysis of these articles shows that mainstream journalists for the most part do not understand how general practice works, and that they have uncritically taken the DH formulations and promises as fact, when in fact they often do not make sense.

 See my post.

In time, the mainstream press may well wake up and look into this issue.

b. The problem of capacity:

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 is to shrink our practice area further a few months ago. So there is no way we could cope with an influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised), we are drowning as it is.

I came across an example which illustrates this problem recently. 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 currently registered patients, all of whom reside within their practice boundary.

Another example which illustrates this in a farcical way. The DH chose City and Hackney as one of their pilot sites. The City 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. 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. 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.

See my article.

4. On Burnham visit to King’s Fund, see my post.

5. On Government ‘consultation’, see my post.

6. On the Choice of GP pilot, see my post.

 

 

 


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

14/04/2013

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

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

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

For more information, see www.gpboundaries.org

*

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


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

17/03/2013

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

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

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

Why? Ask Virgin Care, KPMG, and McKinsey.

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


Tower Hamlets CCG Chair letter to local MPs on Section 75 Regulations

09/03/2013

2nd Floor Alderney Building

Mile End Hospital

Bancroft Road

London E1 4DG

Jim Fitzpatrick MP

Rushanara Ali MP

1st March 2013

Dear Jim and Rushanara,

Re: Section 75 Regulations and EDM 1104 (Early Day Motion)

We are extremely concerned about the regulations to bring into effect Section 75 of the Health and Social Care Act.

As commissioners we are determined to use all of the tools at our disposal to deliver the highest quality services for our patients and the people of Tower Hamlets.  To do this, we need to be able to commission integrated services which place the patient in control and provide a seamless passage across health and social care and through different health services.

Our view is that clinical commissioners must be provided with the freedom to use the full range of procurement tools including integration, collaboration, innovation pilots and a variety of competitive tendering mechanisms where appropriate. These must be based on achieving the highest quality and best value for patient outcomes rather than price alone, and give appropriate weighting to delivering the best care.  To do this we need to be free to choose what the most appropriate tool for any given situation is. Our concern is that the regulations laid under Section 75 of the Health and Social Care Act will be interpreted in a way that will obligate commissioners to carry out virtually all commissioning through competitive tendering.  This may negatively affect the way that seamless care can be delivered.

It is essential that CCGs are given greater freedom to choose when and how to procure new services and that the risk of referral to Monitor or the courts does not place a chilling effect on commissioners’ ability to take a more inclusive route if that is what they feel is best for patients, especially in relation to the care of complex patients, where services may be best provided by a small number of connected providers.

We all know that we face massive financial challenges in the NHS combined with managing a new system that has separated Primary (General Practice), Secondary (Hospitals) and Tertiary (Specialist) commissioning.

We do not underestimate this challenge and are determined to provide a high quality service for all our patients. Restricting our options will reduce our ability to provide the best for our patients and make it so much more difficult to manage the financial challenges.

I hope you feel able to support EDM 1104, which calls for a full debate on the issues raised by the Statutory Instruments laid under Section 75 of the Health and Social Care Act.

Best wishes

Dr Sam Everington

Chair

NHS Tower Hamlets CCG


Will the real Neal Bacon please stand up?

09/03/2013

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

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

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

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

And then this helpful page from Dr Rita Pal.

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

 

 

 


Neil Bacon’s misunderstanding about how general practice works

09/03/2013

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

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

This is what I posted on his blog piece:

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

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

Everyday Life is the Path

08/03/2013

‘Everyday life is the path’: about 30 years ago I came across this phrase in Zen Flesh, Zen Bones, compiled by Paul Reps.

I have decided to try to write brief, daily (or almost daily) posts about what happens in my primary care day.

Friday is my day off. But I have been coming into work on Fridays since 2006 when we switched to a new computer system and I started coming in on Fridays in order to do the extra work involved in making the transition.

This morning I did some desk work and then went to a sheltered accommodation block in order to take blood from one patient I had seen earlier in the week, and in order to review another patient in the same block. While I was there, the ‘scheme manager’ (previously called the ‘warden’) asked me to see another of our patients. And we spoke about another who concerned her.

And then she said how much she appreciated the service our practice provided. I thanked her for her positive feedback, and said we were doing our job. Then she said that all the negative press about the NHS and GPs really frustrated her.

Earlier this morning I had seen a post by Roy Lilley, which I would recommend. He has been attending the Nuffield Trust summit on the question ‘Is the NHS Fit for Purpose’.

Walking back to the surgery I daydreamed: ‘Is the Department of Health fit for purpose? Are the Health Ministers fit for purpose? Is a methodology that involves (willful) ignorance, misrepresentation, PR, and lies a methodology that is “fit for purpose”?’ And I was thinking of this.

A thought: if you want health professionals to do a good job, it is important that they feel positive, that they feel proud about what they do. And they need enough time to do the job. (And a few other ingredients: I’m not listing them all tonight).

Further work today: teaching medical students, seeing patients. Now it is 8pm on my day off and I am going on 2 more visits, both in another home, with higher dependency.

One comment on my particular issue, that of GP practice boundaries which the DH and Government want to abolish: I was able to see three patients this morning quite efficiently, in the same block. I got there on foot. Tonight I am seeing 2 patients at essentially the same address. I will ride my bike to get there, on my way home. These two homes are within our practice geographical area, within reach of the practice. Without a limited geographical area we would not be able to visit these patients efficiently, or at all.

What would the scheme manager say then?

(this was a bit longer than I had intended)