Neil Bacon’s misunderstanding about how general practice works


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 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.)

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
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
(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


‘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)

Two members of Health Select Committee respond to my email on GP practice boundaries


I emailed members of the Parliamentary Health Select Committee earlier in the week. I have received a reply from two of the members, Sarah Wollaston (herself a GP), and Barbara Keeley. Here are their replies:

Sarah Wollaston:

Dear Dr Farrelly,

This does look like the kind of issue that the HSC could look at but we have many outstanding and potential enquiries and the whole committee vote to decide on the order in which they are examined. I’d be happy to see this added to the list as part of the wider review of GP services and the important issue I’ve already raised of understaffing. I agree this issue of boundaries is very important.

Best wishes,



Barbara Keeley:

Dear Dr Farrelly,

Thank you for this, it is very worrying.

As far as I understand it, the brief of the Health Select Committee is to hold the Department of Health to account:

The Health Committee is appointed by the House of Commons to examine the policy, administration and expenditure, of the Department of Health and its associated bodies.” (quote from Committee’s page on the website)

So the matter you raise would fall within the Committee’s remit.

Best wishes

Barbara Keeley MP

‘This is why practice boundaries exist’


An article [link below] appeared in the BMA News in January 2012 illustrating why, from a purely practical point of view, GP practice boundaries exist. I have blogged previously with examples from our own practice [link below].

The article makes a number of important points: looking after people at some distance from the practice is time consuming. Not only is it difficult to look after these individuals well and safely, but to do so will impact on the service as a whole (so the service and care to the local population is affected).

This is why practice boundaries exist    Click here

Examples of patient care at a distance    Click here



13. How can they be so stupid? Corporate lobbying?


I put a question mark after corporate lobbying simply because I have no direct proof myself of this activity. I am close to certain that this activity has taken place over time with respect to the issue of GP practice boundaries, and I think it is likely that this plays a central role in driving this policy. The politicians talk about patient choice, but underneath it all is really an aim to de-regulate English general practice and open it up in quite a new way to for profit companies.

How and why?

At present practices cover a limited geographical area. This limits the number of patients. Remove this factor, make registration free of geography, then it opens up an entirely different model which can be exploited by companies like Virgin Care.

These companies can set up medical centres in major cities, wherever is most profitable. They will attract a clientele of mobile, essentially healthy professional people. They will not have to deal with these patients when they are actually sick because they will be too unwell to travel to their centres; someone else will have to visit them. The elderly, people with chronic diseases, will remain registered with local GPs.

It will be convenient for the mobile and well, and profitable for the firms. But it will not deliver primary care in any real sense, and will in essence be a virtual asset stripping.

6. How can they be so stupid? Stupidity-to different degrees, at times grotesque


The Oxford Dictionary of English has next to nothing for stupidity. For ‘stupid’: lacking intelligence or common sense; dazed and unable to think clearly: apprehension was numbing her brain and making her stupid

lacking intelligence: yes, this is relevant

lacking common sense: yes, definitely

dazed: they should be

unable to think clearly: yes, many examples of this


5. How can they be so stupid? Ignorance, wilful and unwilful


With the issue of GP practice boundaries, there is in general a very limited  understanding about general practice actually works, about how good quality general practice works. Even our hospital doctor colleagues often do not understand how it works.

Good quality British general practice is a very complex technology which serves local communities in geographical areas. You need to have an understanding of this and how it works. Otherwise, you are ‘ignorant’.

A GP colleague of mine has been to a number of events organised by the Department of Health in recent months. She has been struck by how ignorant the people from the Department of Health are about how general practice works, how general practitioners work, how good quality British general practice works.

‘Wilful ignorance’: don’t confuse me with the facts.

3. If it is so stupid, why are they doing it?


I have reflected for over 2 years about this. If the proposal to allow patients to register with any GP in England, regardless of where they live, is so stupid, how is it that all three main political parties back the proposal, the Department of Health backs the proposal, journalists do not question the mechanics behind it, and, in the ‘Consultation’ over three quarters of the members of the public who responded allegedly backed the proposal?

I would say there are a variety of reasons, but all in the end come down to a misunderstanding of the situation, of the facts. This misunderstanding is the result of:


Ignorance (wilful and unwilful)

Stupidity (to different degrees, reaching at times the grotesque)

Misinformation (wilful and unwilful)



Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)

1. This really has to stop


For over 2 years now most mornings I wake up earlier than I need to and my mind fixes on the issue of GP practice boundaries and, in one form or another, I think ‘How can they be so stupid?’ ‘They’ being the politicians, the Department of Health, journalists, think tanks, patient representatives. I don’t on the whole include members of the public, simple citizens in this. Because they are being fed stuff by the politicians, journalists, think tanks, and who could blame them for thinking it is reliable stuff?

Why am I doing this? Why am I writing this early on a Bank Holiday morning when I could be in bed sleeping, reading a book, gardening, or going to work to try to catch up on the massive backlog (which I will do later on as it happens)?

I came to medicine late, I was about 6 years older than my peers at medical school. I made a positive choice to become a general practitioner, because I welcomed the chance of working in a community, with families, over time. My wife and I started in our practice in Tower Hamlets 21 years ago. We, and our colleagues in the practice, try to provide a good service to our patients, and to create a healthy environment in which to work.

We, like all GPs, have a geographical practice boundary. To register with us you need to live within that geographical area, if you move outside that area you have to find another GP in whose practice area you live. It seems harsh, but there are a number of practical reasons for it. What I tell patients when they move is simply this: it is important that you be able to get to the surgery easily or for us to get to you easily if you are sick. (There are a raft of reasons why this, from a practical point of view, is necessary). Patients nearly always see why this is necessary.

We have quite a lot of experience of looking after patients who have moved out of the area and not told us. They have continued to use us as their GPs but it simply does not work properly, for a variety of reasons (in some cases it is unsafe, and can be fatal). So we are pretty firm with people on this score, but give them adequate time to find a new GP.

There is another aspect to this question. We work in Bow. We have a limit to how many people we can look after; if we exceed this capacity, the quality of the service we offer declines and the dynamics within the organisation become unhealthy. So we have an upper limit of the number of patients we will register. So if a patient moves away from Bow (to say Brixton), that patient’s place is then taken by another resident of Bow who wants to join us.

So when, in September 2009, I heard that Andy Burnham wanted to abolish GP practice boundaries and give people ‘real choice’, I thought: ‘How can that man be so stupid?’

Then there was the ‘Consultation’ in March 2010; the General Election which brought us the Coalition Government and Andrew Lansley; Andrew Lansley’s vision to bring everyone more choice, and his commitment to abolishing practice boundaries.

But the trouble for me was that I actually worked in the field that they were talking about, and I had daily reminders about the fact that general practice is a community based technology tied to geography, and that to severe its tie to geography simply did not make sense. It simply did not add up. There was a cognitive disconnect.

And so I woke up early asking the question, ‘How can they be so stupid?’ And having followed this issue over the past 2 years, I am still waking with this question, in fact it is seeming to me to be more and more stupid.

But it really has to stop.


East London LMCs advise boycotting ‘Choose Your GP’ pilot


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