These notes are to accompany the ‘opinion piece’ I was asked to write for Pulse, the GP weekly, on the matter of the Government’s proposal, contained in the Health and Social Care Bill, to abolish GP practice boundaries. There are links below to back up my assertions.
In essence the issues are as follows:
The proponents of the policy argue that:
- GP practice boundaries are anachronistic and no longer serve any purpose
- The are ‘old fashioned’, and limit patient choice
- That abolishing practice boundaries will give patients ‘real’ choice and drive standards up
- They point to the results of the New Labour/Department of Health ‘consultation’ on GP boundaries March-July 2010; over three quarters of the public who replied to the ‘consultation’ questionnaire were in favour of the policy to allow patients to register with the GP practice of their choice, ‘anywhere in England’
To the man or woman in the street, this sounds like a good idea, what’s not to love about it? Having choice is a lot better than limited choice.
But people who actually work within primary care will know from first hand experience that this proposal simply does not add up, that looking after patients who live at a distance creates all sorts of problems.
- Good quality British general practice is a complex technology. It serves a local population, and the vast majority of the transactions are local ones.
- Distance from the practice is a barrier to care: patients attend less
frequently, delay seeing us (sometimes inappropriately), save things up and bring more items to the consultation (which cannot be dealt with effectively), are more likely to not attend booked appointments, are less likely to attend for appointments that we initiate (chronic disease monitoring).
- Patients who are not local cannot integrate with local essential services: the community mental health team, local health promotion initiatives, physiotherapy, chiropody, social services, local community pharmacists. We in primary care build up relationships with all these services, and cannot duplicate this easily with a myriad of similar services in different parts of the country.
- Sometimes it is unsafe. Patients need a visit because they are too ill to travel (made worse by the distance), and they are too distant to visit without putting an unsafe burden on the practice which will impact on the service that we are trying to offer to the local population.
- Looking after people introduces a number of inefficiencies which are a drain on practice time which is an important resource. And this at a time when we are being asked to make efficiency savings.
- If we register patients who are not local, then this may mean not registering patients who are local (if there are capacity issues). This introduces the risk that over time local practices will no longer be serving a local community but a mixture of local and non-local patients.
I assert in my opinion piece that the Government and DoH are offering something they cannot deliver. They are either offering this out of ignorance (which is quite shocking) or because they have a hidden agenda and this offer of ‘choice’ is therefore an act of deception, an act of corruption (which is even more shocking).
What is the evidence?
The politicians and DoH are asking us to do something which most of us GPs and practice staff know simply does not work. They are asking us to adopt a policy which will make the system malfunction. In their communications the gloss over entirely any problems, any practical issues, and just repeat, like a mantra: ‘we must offer patients choice’, and ‘over three quarters of the public are asking us for this’. That is in essence the argument for. They say nothing about the ‘consequences of this choice’.
I sought evidence from Andrew Lansley in March 2010 (when he was in opposition, and pushing this policy) that he understood the complexity of quality British general practice, and that he had carried out a feasibility study or risk assessment. It took some perseverance on my part, but I eventually got evidence that he had not carried out any sort of risk assessment (see below).
New Labour’s record is contained in the so-called ‘consultation’. This is really a blatant public relations exercise which sells something it cannot deliver; the questionnaire that members of the public and health professionals answered was skewed in a way to make it more likely that a member of the public would answer in a given way (to vote in favour; in fact, it is difficult to see why members of the public did not all vote in favour). So the consultation process was an exercise whose aim was two-fold: first, to make it appear that New Labour were taking this seriously (so outflanking the conservatives), and offering something to the public which might garner them votes, and then, second, coming up with ‘evidence’ that the public are in favour of this policy and using this as an argument to implement the policy. The consultation documentation is misleading, a deception. The public were deceived, and parliament was deceived. And the results of this deception are being used by ministers and the DoH to implement a foolish policy.
But why would they want to do it?
At present there are a handful of English GP practices owned and run by private, for profit companies. But they have to operate at a local level. This is quite restrictive. By abolishing GP practice boundaries, the whole framework is opened up for these companies. They can set up health centres which will be able to register patients from anywhere. They will be glorified walk in centres, for the mobile well. They’ll leave home visits to someone else, and those who are really ill will find quickly that they need a local doctor. It is highly likely that for many years the likes of Kaiser Permanente and United Health and McKinsey have been whispering in the ears of ministers and DoH policy makers, and this is why there is a push to abolishing GP practice boundaries.
What can we as GPs do?
I think it is essential to bring this issue into the public arena. It is quite simple, really. Most of us (there will be a few mavericks, ‘doctor-preneurs’, who will of course be in favour because that is where the money lies) will feel that this is a terrible policy which will undermine good quality general practice and be a threat to local communities. In the interest of maintaining good, safe standards, we should be quite vocal about this, draw it to our patients’ attention. And the GPC MUST RESIST this very very robustly.
We can refuse to do it: This would be a form of strike, but a strike which actually would not harm the service at all, in fact would be protective of the service. You see, we have a very strong argument on our side; the Government have a house of cards which will unravel once our patients are aware of the facts (which are not terribly complex), and the media begins to take an interest. Indeed, I think the Government will want to avoid a light being shone on this issue because it is so corrupt.
That is why I say that this issue is a scandal in search of an audience.
[Your views are welcome, comment below]
Links to documentation:
1. My email exchange with ‘Andrew Lansley’. This is a shocker.
I have emailed the Lib Dem MPs asking them the same question I asked Lansley. So far, no answer. I will of course persevere.
2. Patient leaflet for the Government ‘consultation’ on Choosing Your GP, March 2010.
If you read this leaflet, why refuse the offer?
3. Full ‘consultation’ document (includes the questionnaire).
I would be interested in the views of professionals who design questionnaires. What do you think of the design of this questionnaire?
4. Royal College of General Practitioner’s response to the ‘consultation’
5. Concrete examples from our everyday work.
My email exchange with The King’s Fund
My email to the Patient’s Association
My email to an MP
Is this the future? Virgin Assura Medical
Strategy of US for profit companies: read this
Trust in professionals poll 2009