My submission to the Listening Exercise on choice & competition

29/05/2011

I am a GP in Tower Hamlets; my wife and I took over a singlehanded practice as a jobshare 20 years ago. We now have 2 part-time GP colleagues, and a list size of 3,520. I am sceptical about this exercise as I do not believe the people in power will use this feedback in any significant way. I say this because I believe they have their minds made up and will do what they can to proceed with their plans unchanged. This ‘pause to listen’ is largely a PR exercise. Also: the previous government established a ‘consultation’ about the ‘Choose Your GP Practice’; the conclusion after the consultation, issued a few months after the present coalition government took over, changed absolutely nothing. They used what they wished to back their plan, and ignored the rest.

But it is important to speak out, so here goes. Competition: for several years the Department of Health (DH) has trumpeted competition as a way of improving primary care (=general practice). I must say that in 20 years I have never felt in competition with my GP colleagues in Tower Hamlets. Not even for 5 minutes. If we do a good job, if we aim for good quality, it is because we want to provide a good service, we want to be up-to-date with our practice, it is because we take pride in our work. A few days ago Stephen Dorrell was quoted as saying “The idea there is no competition in the NHS is just bonkers. There are few more competitive groups of people than good doctors. They compete and that improves the care of patients.” I don’t know what he means by this; it does not ring true for me. I would recommend the writings of the American surgeon Atul Gawande; these are thoughtful accounts of the complexity of providing good quality humane care to sick people. What makes doctors better, is not ‘competition’ with each other (in fact, collaboration between professionals is a very important ingredient).

A few years ago a practice in Tower Hamlets became vacant through the retirement of the incumbent GPs. The practice was put out to tender under the present rules; two local Tower Hamlets practices put in bids, as did Atos Healthcare, a private multinational. Atos won the bid as they had underbid the local bids. At the time I wondered if they would be able to provide good quality general practice. From the stories I have heard, they were not. They scored at the bottom end on a number of measures when compared to other Tower Hamlets practices. Did the people who champion competition come to Tower Hamlets and observe this, have they learned a lesson from this? The local planners have learned something, but the Andrew Lansleys and DH people have not. You can read about this story at this link: http://bit.ly/mOMyeI

One particular issue that has vexed me is that of GP practice boundaries. When my wife and I were interviewed in 1991 (please note that it was the GPs who were interviewed in 1991, not some men in suits from Atos who were not doctors as was the case outlined above; when Atos were awarded the contract they still did not have the doctors who would actually deliver the service identified; I know because they later tried to recruit GPs and sent me a job application), we were asked what we were going to do about the ‘outliers’ (the patients who lived outside the practice area). This because in 1991 it was thought to be bad practice to have patients living at a distance from the practice. So we have been quite firm about our practice area; when people move outside the area, we ask them to register with a local GP. They are often reluctant to do so but, with an explanation, they understand the rationale. We have in essence carried out a pilot study of this issue over 20 years and our experience has been that the further away a patient lives, the worse the care they receive, and the more complex it is for the practice to deliver that care. In some cases it is unsafe. So when Andy Burnham proposed in 2009 (after being chided by Andrew Lansley who was then in opposition) that New Labour would abolish practice boundaries within a year, I was horrified. It seemed a parody; if there was a measure that would undermine care, stretch resources, and be unworkable, this was it. And the government was behind it, and the DH. [see my email exchange with ‘Andrew Lansley’; & The King’s Fund]

And this raises the issue of choice. Choice is the (stated) rationale behind this proposal. Choice seems to have a hypnotic quality: you say ‘choice’ and people seem to go into trance, and switch off their critical faculties. With reference to the abolishing of GP boundaries, when you will (theoretically) be able to register with the practice of your choice anywhere in England, think about this for a moment. Let’s say you know of a good practice 5 miles down the road from you (or even 20 miles or 100 miles); you must understand that this practice is currently working at full capacity or close to it. They do not have significant space for more patients; sure, they might be able to expand a bit, take on a few more doctors, build an extension, but they will have a limit. And besides, if they grow significantly, they will not longer be the practice they were before. And if you were hoping to see Dr Special, well Dr Special is already fully booked as it is today. How is she or he to have the time to make their skills available to you (and all the others like you who wish to ‘choose’ this doctor)? It is a mirage, a con, a scam. There are some who say that in fact the (unstated) aim of this policy is to open the door to providers on the model of American HMOs (health maintenance organisations; for further information see Wikipedia).

There is a very major problem in this whole debate, with all these issues (and they are multiple, and complex). And that is ‘methodology’. The method that seems to prevail at the moment is to take an ‘idea’, and then try to implement it without actually taking into account the most basic practical issues. So when Andrew Lansley tells you that there will be no decisions made without you, ask yourself just what does this actually mean and then try to model it, think of how it is going to work (along with all the other processes that have to work alongside it).

So what do we need instead? A brief sketch of my thoughts. We need to ask the question: what is needed? what do I want? what is essential? in the health service of this country. Then we have to ask: ok, what is needed in order to provide this? What are the structures, processes needed? What are the different possible ways of doing this, how would they work? What would they cost? What would be the unintended consequences? How would we know if it was working? How would we know if it was not working? We really need to move from the level of the abstract (choice, modernisation, reform…), to the concrete. And honesty, transparency, and an evidence-based approach are necessary. That’s it from me.

If you want further details, see www.onegpprotest.org


My email to MPs with surname beginning with G

19/05/2011

 

I am a GP in Tower Hamlets. I have a number of concerns about the Health & Social Care Bill, but have been focusing on one rather neglected one: the policy to abolish practice boundaries and allow people in England to register with the GP practice of their choice anywhere in England. All three major parties support this policy, in one form or another. At first glance, this seems like a good idea, who would not like to have greater choice? But there really are a great number of practical problems which will make it unworkable.

When my wife and I were interviewed in 1991 to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ on the list. At that time it was regarded as bad practice to have people living at a distance from the practice, and good practice to have a practice population which was close to the practice. In 20 years of practice, in a myriad of ways and on a daily basis, I have seen the difficulties that occur when patients move away and continue to use us as their GPs. Managing people’s healthcare when they live at a distance is more difficult for the practice, more difficult for the patient, and leads to situations that are sometimes unsafe. I am bewildered when I hear politicians and DH people say that practice boundaries are ‘outmoded’, ‘old fashioned’, ‘anachronistic’.

I tried to raise my concerns with Andrew Lansley in March 2010; for my email exchange  http://bit.ly/f4iTA1

If you want to find out why this policy is problematic, go to www.onegpprotest.org and follow the links for politicians.

I am aware that there is a convention that MPs only deal with correspondence from their constituents. I am not expecting a response. Consider me a lobbyist. An unpaid lobbyist. Why am I spending all this time writing to MPs and others? Because I think the good quality British general practice is a treasure, and this policy will undermine general practice. It may even be a sinister covert move to privatisation. For the reasoning behind this comment, http://bit.ly/jCHp2k & http://bit.ly/ePWSQ8   

I don’t harbour illusions about my efforts, but I feel we have to speak up, at least I will be able to say that I tried.

 


Are GP practice boundaries good or bad? My email to the King’s Fund

14/05/2011

I am a GP in Tower Hamlets. I have a particular concern about the proposal to abolish GP practice boundaries and allow patients to register with the practice of their choice, anywhere in England. When my wife and I were interviewed in 1991 to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ on the list. At that time it was regarded as bad practice to have people living at a distance from the practice, and good practice to have a practice population which was close to the practice. In 20 years of practice, in a myriad of ways and on a daily basis, I have seen the difficulties that occur when patients move away and continue to use us as their GPs. Managing people’s healthcare when they live at a distance is more difficult for the practice, more difficult for the patient, and leads to situations that are sometimes unsafe. I am bewildered when I hear politicians and DH people say that practice boundaries are ‘outmoded’, ‘old fashioned’, ‘anachronistic’.

In his closing remarks after a speech by Andy Burnham at the King’s Fund on 17 September 2009, your then CEO said this:

On the plan to make it easier for patients to choose their GP, Niall Dickson said: ‘The vast majority of patients are more than happy with their GP, but the restriction on where they can register is an anachronism and the government is right to sweep it away. There are details to be worked out, but it should not be impossible.’

As you will be aware, this proposal is part of the Health and Social Care Bill.

The King’s Fund says that it ‘seeks to understand how the health system in England can be improved.’ Can you tell me what the King’s Fund thinks at present on this issue of GP practice boundaries (or practice areas as they are also called)? Would abolishing them improve the health system in England? If yes, then explain how.

See Andy Burnham Speech

See King’s Fund Response to Speech

Guardian report of the event


The plot thickens

13/05/2011

 

On Wednesday evening, I went to a talk given by David Price, co-author with Allyson Pollock of a recent British Medical Journal article How the secretary of state for health proposes to abolish the NHS in England.

In the course of his talk, he mentioned work done by the American doctor and academic Howard Waitzkin, analysing the way in which American healthcare multinationals gained entry to the healthcare markets of Latin American countries, in an effort to boost their profits. This was largely at the expense of the host nation’s healthcare system and health economy. David Price asked: this is how these companies behaved in Latin America and other developing countries, is England next?

I managed to find an article by Waitzkin and a colleague which makes unsettling reading. And it adds to the hypothesis I have outlined in the previous post.


The Plot Against the NHS–some excerpts

08/05/2011

 

[Here are a few excerpts from Colin Leys & Stewart Player, The Plot Against the NHS, Merlin Press; read Colin Leys’ pre-publication lecture     I would strongly advise anyone interested in the future of health planning and provision in England to get a hold of this book, and to read it. And send a copy to your MP immediately.]

 

So in spite of its great popularity Britain’s most famous postwar social achievement was unravelled through a series of step-by-step ‘reforms’, each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more ‘choice’, to achieve ‘world class’ standards, to make the NHS more ‘patient-centred’—anything but the real underlying aim of the key strategists involved, to turn health care back into a commodity and a source of profit.

Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders—inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘special advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions—and the House of Commons Health Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.

Each ‘reform’ needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.

(Pages 5-6)

Unfortunately the marketizers continued to advocate market models of care even when experiments showed that market-based imports were not efficient at all—as with UnitedHealth’s ‘Evercare’ programme, for example. Evercare, which the huge American HMO UnitedHealth was paid a large sum to test in four regions ofEngland, was supposed to reduce emergency hospital admissions for elderly patients by 50%. But when it was evaluated it turned out to be unlikely to cut admissions by more than one per cent. The marketizers had evidently not reckoned with the fact thatEngland’s system of primary care was already accomplishing what Evercare does in theUS, where there is no free primary care. The main lesson the Department of Health seemed to draw from this experience was not to evaluate such experiments.   (Page 8)

By 2010 marketization clearly entailed not just the possibility but the longer-run probability of privatization. Yet the fact remains that all the evidence shows that privatization make health care more costly—and worse. The evidence from theUSconfirms what economic theory says, that markets will not produce good health care for all, as the NHS is pledged to do.

A Treasury document published in 2003 clearly outline the reasons why this is so: price signals don’t work in relation to health care; the consumer lacks the necessary knowledge, creating a risk of overtreatment; there is a potential abuse of monopoly power; it is hare to write and enforce contracts for medical treatment; and ‘it is difficult to let failing hospitals go bust—individuals are entitled to expect continuous, high-quality health care wherever they are’.

Why was all this ignored? If the strategists in the Department of Health thought they had contrary evidence or superior theory they should have come out openly and said so. But they were never called on to defend their ideas, precisely because they proceeded so covertly.

A 2010 survey of 20,000 patients in eleven industrialised countries for the US Commonwealth Fund found that the NHS was almost the least costly healthcare system of them all, and at the same time gave one of the best levels of access to care. Other countries not only spent more per head but also charged patients directly, reducing equality of access. OnlySwitzerlandreported faster access to care, butSwitzerlandalso spent some 35% more per head than theUK. OnlyNew Zealandspent less per head, but one in seven New Zealanders said they skipped hospital visits because of cost. To ignore all this evidence and embrace the idea of replacing one of the most cost-efficient health systems in the world, as well as one of the fairest, with one modelled on the most expensive and unequal system (the American), sets a new standard for ideologically-driven (and interest driven) policy-making.

But the NHS has not only worked well, providing high-quality, equal care for everyone, free of charge, at low cost: it is also the historic achievement of millions of people—those who fought to establish it, those who have spent their lives working for it, and everyone who has paid their taxes to build it up over the more than sixty years since it was created. Its founding principles of comprehensiveness and equal access for all have been core values of modern British society. Working to marketize it, and finally privatizing it, without any democratic mandate—without even explaining that aim to parliament of the public, is as close as it gets to being not just unscrupulous, but actually unconstitutional. The question is whether the English people—Scotland,Wales, andNorthern Irelandhaving escaped the plotters’ reach—will accept having this precious part of our heritage filched from under our noses.

(Pages 9-11)


The Plot Against the NHS: this helps makes some sense of apparent stupidity

14/04/2011

 

I would strongly recommend the transcript of a lecture which introduces a book called The Plot Against the NHS.

I’ve started reading the book. It is now becoming clearer why the DH and Labour government have been attempting to implement stupid policies.


My email to Liberal Democrat MPs

12/04/2011

 

Dear Liberal Democrat MPs,

I am a GP in Tower Hamlets. I am emailing all MPs, one letter at a time. I have managed only the A B & C’s so far. I am writing to you as a group before getting to the D’s because you seem to hold the power at the moment.

Most people seem to be focused on GP commissioning and future providers. These are important issues. I have focused on a policy which has received little attention: the proposal that English residents can register with any GP in England. I am told that all three main political parties support this polciy. It sounds like a good idea, what’s not to like about it? But it is vital that you look at the effects of such a policy.

If this policy meant that general practice in England (because Scotland, Wales, Northern Ireland are not proposing this) was, as a whole, undermined by this (became less efficient, more costly, at times unsafe), would you support it?

I have been a GP principal for 21 years. UK general practice is a wonderful thing, when done well. I am privileged to be in this job. I am spending hours writing to people like you because I believe that quality general practice is being eroded by successive governments.

If the KGB had infiltrated the Department of Health and the House of Commons, and if its aim was to undermine British general practice, then this policy (among others) might be the sort of thing they would try to implement. I offer this as a surreal metaphor. And yet this is how misguided this idea is.

I emailed Andrew Lansley a year ago to check if he really understood what this policy would do. Here is the exchange that followed:

https://onegpprotest.org/2011/01/22/an-attempt-at-transparency-from-andrew-lansley/

The New Labour government carried out a ‘consultation’ on this issue a year ago. This was a PR exercise which was full of distortions, inaccuracies, and omissions. The Royal College of General Practitioners submitted a response. Have you read it? If not, here is the link:

http://www.rcgp.org.uk/pdf/RCGP_response_DH%20-%20Your%20Choice%20of%20GP%20Practice.pdf

For more information, see my blog  www.onegpprotest.org

I understand that the convention is that MPs act on behalf of their constituents. I am not writing to you as a constituent but as a citizen who happens to be a GP. I do not expect a reply, but I ask merely that you check the facts so that your vote is not a blind act of obedience.

 Best wishes,

 George

The Tredegar Practice 35 St Stephens Road London E3 5JD

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


My email to MPs, surname beginning with C (includes Cameron & Clegg)

10/04/2011

Dear MPs,

I am a GP in Tower Hamlets. Of course you know there is a lot of controversy around the Health and Social Care Bill, and that the coalition government has taken pause to re-think it. Within this Bill is a proposal to allow people in England to register with the GP of their choice, anywhere in England. Apparently all 3 major parties support this idea. It sounds like a perfectly good idea, who would not like to have this choice? The trouble is in the implementation, in the actual world.

 If you wanted to introduce a design fault into the system of primary care so as to undermine it (like a virus to infect IT systems), this would be a good one. Andrew Lansley has not thought this through (or if he has, he is not letting on; https://onegpprotest.org/2011/01/22/an-attempt-at-transparency-from-andrew-lansley/ ), the Department of Health has not thought it through (though they will say they have carried out a Consultation; this Consultation was really only a PR exercise, another New Labour ‘dodgy’ dossier). See the Royal of College of General Practitioner’s response to this ‘Consultation’: http://www.rcgp.org.uk/pdf/RCGP_response_DH%20-%20Your%20Choice%20of%20GP%20Practice.pdf

 I am a humble GP trying to do a good job and provide a good service to our patient population. Please do not plan and implement policies which make this more difficult. I would rather you fiddled your expenses than legislate these sorts of policies. For more information, see my blog   www.onegpprotest.org

  Best wishes,

 George

 The Tredegar Practice 35 St Stephens Road London E3 5JD

  http://twitter.com/#!/onegpprotest


If you are a politician…

27/02/2011

I appeal to politicians of whatever political party to look into the fine print of the ‘Choose Your GP Practice Anywhere in England’ policy. I know that this sounds like a good idea. Of course, who would refuse the opportunity of choosing whatever GP practice they wished in the whole of England? That can’t be a bad thing! Oh, yes it can…

For the difficulties created by the registration policy enshrined in current GP Contract 2004, click here. This will prime you to consider more clearly the implications of abolishing practice boundaries, and the problems of capacity.

For a brief outline of the problems inherent with Choosing Your GP Practice anywhere in England, click here.

For my email exchange with an MP, click here.

For my email exchange with ‘Andrew Lansley’, click here.

(Please feel free to comment, protest, challenge….)


My email to MPs, second half of the B’s

19/02/2011

 

I am a GP in Tower Hamlets. I am laboriously writing to every MP. You are the 2nd half of the B’s (there are a lot of you…). I was hoping to watch a film tonight, but am writing to you instead.

I am writing to alert you to one of the policies contained in the the Health and Social Care Bill: the proposal, backed by all three parties I am told, to encourage people to register with the GP practice of their choice, anywhere in England. This sounds like a perfectly good idea until you actually look at the practical implications. The Department of Health have not thought it through, Andy Burnham with New Labour’s ‘dodgy’ consultation did not think it through, Andrew Lansley has not thought it through.

I appeal to MPs of goodwill: look into this. Don’t take declarations of ‘Liberation’ and ‘Choice’ to lull you.

See my email with ‘Andrew Lansley’ on this issue before the General Election:

https://onegpprotest.org/2011/01/22/an-attempt-at-transparency-from-andrew-lansley/

See the Royal College of General Practitioners response to Andy Burnham’s so-called consultation:

http://www.rcgp.org.uk/pdf/RCGP_response_DH%20-%20Your%20Choice%20of%20GP%20Practice.pdf

Further details are contained in my blog, link below.

I wish you all well,

George

The Tredegar Practice, 35 St Stephens Road, London E3 5JD

www.onegpprotest.org

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