11. How can they be so stupid? Cognitive Muddle

05/06/2012

At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.

It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’

So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’

Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.

Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.


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

05/06/2012

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

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

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

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


8. How can they be so stupid? Duplicity

05/06/2012

Duplicity:Oxford Dictionary of English: deceitfulness; archaic the state of being double.

Andrew Lansley gave a speech to the Royal College of General Practitioners’ annual conference in October 2011. I did not attend but fortunately the speech is available on video, as are the questions and answers after the speech. So I was able to listen to these. What he had to say about GP boundaries was actually not unreasonable, he seemed to have understood the problem (‘Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this.’; whatever was done had to work, they had to find ways that worked; ‘I’m not abolishing practice boundaries…’). But I was sceptical: let’s see what happens. A few weeks later the GPC signed a contract for 2012-13 which agreed to a pilot on GP practice boundaries, and for asking practices to create ‘outer practice boundaries’ which retained patients who moved from within the practice boundaries. This was not unreasonable, but I remained sceptical: how independent and probing would the ‘independent evaluation’ of the pilot be?

Then came the launch of the pilot, at the end of December 2011:

It allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

Health Secretary Andrew Lansley said:

‘Many patients are happy with their local GP practice, but a significant minority have problems registering with a practice of their choice. This pilot will mean patients taking part can access the high quality care they deserve in a place and at a time that suits them.

‘That’s why I believe patients should have the freedom to choose a GP practice that suits their lives, and not be restricted by geographical boundaries.’

He did not really believe what he said to the GPs in October. He was intelligent enough to know what sort of thing he had to say in order not to be eaten alive, but his intention was, and still is, to plough ahead with the abolition of practice boundaries. And this is how it was reported in the press.

In this sense, he is duplicitous, ‘double’, speaks with ‘a forked tongue’. Not to be trusted.

(For text of what he said to RCGP)


East London LMCs advise boycotting ‘Choose Your GP’ pilot

21/04/2012

Pulse has published an article on this, together with the letter.

My comment to the Pulse article:

Congratulations to the East London LMCs for taking this necessary step. Not only will the commuters using local GP practices be using local resources in terms of secondary care, community services, and prescribing costs, but do local practices really have the capacity to look after these additional patients without distracting them from their local registered populations?

PCT clusters throughout England are having to put in place contingency plans to look after patients who register at one of these pilot sites, but who then fall ill at home and need a GP. What is the cost of all of this? Where is this money coming from?

At all sorts of levels this is a crackpot policy. Either Lansley and the secret agents at the Department of Health are remarkably stupid, or, more likely, this policy is actually a smokescreen to de-regulate English general practice. Removing practice boundaries will open up general practice to an entirely different model which will be ‘liberating’ for organisations like Virgin Care, but will undermine British general practice.

They call this a pilot and they say that it will be ‘independently’ evaluated. I predict that as with other piloted policies, that plans to implement the nationwide roll-out will be made before the (sanitised?) evaluation is made public.

I believe it is possible to stop this policy, but this will require persistent clear-headed resistance to the impracticalities & inefficiencies that will inevitably be proposed. A light needs to be shone on this policy: why did none of the 3 political parties carry out a proper risk assessment of this policy? Why did the Department of Health avoid almost any mention of these risks in the so-call ‘Consultation’ two years ago?

It is really just a confidence trick, and the choice it promises is an illusion. The GP you’ve heard such good things about is actually working at full capacity already. The well-functioning practice you may have heard about works well with this population size, within this geographical area. Increase the list size, change the geography, and the system changes.

For more on this, see my blog www.onegpprotest.org


The policy to abolish GP boundaries: a scandal in search of an audience

18/09/2011

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.

6. Miscellaneous:

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


My question to Lib/Dem MPs on GP practice boundaries

08/09/2011

Dear Liberal Democrat MPs,

As you will be aware, one of the policies in the Health Bill is the proposal to abolish GP practice boundaries. You may be less aware that most GPs think this is a very bad idea, and that the GPC will be resisting this ‘staunchly’ in their negotiations with the Government and Department of Health. It is said this this is to be a ‘battleground’ in the coming months.

I am a GP in Tower Hamlets. I have written to you as a group before.

I am writing now to put to you the same question I put to Andrew Lansley in March 2010: do you have a position paper, feasibility study, or related documentation which gives evidence that you have considered not only the benefits but also the risks of this idea [abolishing GP boundaries], and that you understand the nature of general practice (and here I mean quality general practice)?

I don’t know who within the Lib/Dem party is best able to answer this question so I am writing to you all.

Best wishes,

George

The Tredegar Practice 35  St Stephens Road London E3 5JD

www.onegpprotest.org

http://twitter.com/#!/onegpprotest

Plot Against the NHS? Read this: http://bit.ly/ePWSQ8


The issue of GP practice boundaries is creeping back into the news

03/09/2011

I saw an article in Pulse yesterday. The first 2 sentences sum up the situation:

The abolition of practice boundaries is to form a key battleground between the Government and the GPC during this year’s contract negotiations, as talks begin over next year’s deal for 2012/13.

Ministerial sources have told Pulse the Government is determined to press ahead with the controversial policy by next April, despite the GPC’s fierce opposition to the move.

I doubt that this issue will figure prominently in the NHS ‘reforms’ debate in the next few weeks; it will remain off the radar. But as negotiations  between the GPC and Government get bogged down, we will probably see an intervention from David Cameron to this effect: ‘We are trying to offer the English public real choice here and GPs are being difficult and obstructive.’

At some point this issue will become a focus of media attention and then I hope some serious attention will be paid to it. Because when you examine this policy what you find is a total disregard for how general practice in the UK actually works. The Government’s promise of greater patient choice is really, when you look at it carefully, an illusion, a scam. New Labour’s so-called ‘Consultation’ on this issue in March 2010 was dishonest and misleading, and the Department of Health is using the results of this ‘consultation’ to justify the policy:

A DH spokesperson said: ‘The vast majority of patients told us that they want to be able to register with a GP practice of their choice in our consultation on practice boundaries. We aim to give patients far greater choice of GP practice from April 2012.’

Either the Government ministers are incredibly, grotesquely stupid, or there is a hidden agenda. I have been reflecting on this issue for over 2 years now, and I have come to the conclusion that there is a hidden agenda. Abolishing practice boundaries is really about opening up primary care to large HMO-type corporations. At present, having a practice serve a limited, defined geographical patch is quite limiting for such corporations (and there are some running GP practices already). Remove practice areas, and suddenly the possibilities open up. They can attract patients irrespective of where they live. So abolishing practice boundaries would be a form of deregulation, and the people who will gain from this will be these large corporations: ‘Liberating the NHS’: yes, opening things up, ‘liberating them’, for the large private (for profit) organisations who have been (quietly) lobbying for this for some years.

So when Government ministers say they are determined to press ahead with this policy, there is really a great deal (hiddenly) at stake. Because if primary care can be opened up to the private sector in this way, then all else will follow.

What is to be done? It is very important to be clear about the core values of British general practice and to understand how it works, and the ways in which looking after patients at a distance from the practice introduces inefficiencies, acts as a barrier to care, and is in some cases unsafe. It is important also to make clear the systemic distortions this will introduce (local patients being squeezed out by non-local people; how local integrated services will be unable to serve these non-local people).

It is important to stand quite firm against this policy and use honest plain English. This policy is a tissue of lies and distortions and omissions, a house of cards, which simply does not add up.

My intention in the next few months is to assemble further evidence to support this assertion.

In the meantime, you can read (or re-read) my email exchange with ‘Andrew Lansley’ from March-April 2010.

And keep in mind the physicist Richard Feynman’s lapidary statement:

‘For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.’