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


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.


My email to Lib Dems health team


Dear John Pugh, Paul Burstow, and Baroness Jolly,

I emailed Liberal Democrat MPs with a question about GP practice boundaries (see below). One of your MPs emailed me to say I should address my question to the Lib Dems health team, and gave me your contact details.

Briefly, I am a GP in Tower Hamlets. I was appalled when the policy to abolish GP practice boundaries was broached in 2009; quite simply because looking after patients who live at a distance from the practice does not work (we have over the years struggled with this), and is at times dangerous; and there are a number of other reasons why it is a very stupid idea. All three major parties supported this idea.

In March 2010, I asked Andrew Lansley, then shadow minister for health, if he had any documentation to show that he had done some sort of risk assessment of this policy. In the reply that I eventually obtained, it was evident that no assessment had been made.

For the record, did the Liberal Democrat Party carry out any risk assessment or feasibility study about this issue? If yes, may I please have a copy of the documentation showing this? If not, why not?

Best wishes,


The Tredegar Practice, 35 St Stephens Road LondonE3 5JD

Copy by Royal Mail to Baroness Jolly; and copies in post to John Pugh and Paul Burstow

A simple story that illustrates why sick patients need a local GP


Here is another story about caring for a patient at a distance

On a Tuesday in July 2011 I was taking the midday phone calls. A patient who had been seen that morning by one of my colleagues rang for further advice. My colleague had diagnosed a likely pyelonephritis and prescribed antibiotics, and sent a urine specimen to our local hospital for analysis. Pyelonephritis is a serious condition which not infrequently needs hospitalisation. The patient, under thirty and otherwise a fit and healthy person, was having shivers and felt the need for further advice. I told the patient that the ‘shivers’ might be due to a temperature and what to do about that, but that it might also be due to rigors due to the infection spreading to the blood. I advised that he/she continue taking the antibiotics, and take medication to lower his/her temperature, and to ring again if the shivering persisted or if he/she became more unwell.

The next afternoon at about 3pm the patient phoned again. The patient was still quite unwell. As it happens, I had been invited to speak to a group of mainly pyschotherapists about this blog, this Protest, and I was getting ready to leave for this meeting. I could see that the patient lived 2 blocks from the surgery and I thought I could drop by on my bicycle on the way to the meeting. I told the patient that I felt he/she needed to be seen. The patient said he/she would come to the surgery; I said to come straight away.

It took the patient 45 minutes to arrive. I assessed the patient, spoke to the duty medical team at our local hospital; we would continue to manage the patient at home, but if he/she got any worse, hospital review and possible admission would be necessary. I gave the patient a letter, in case he/she needed it.

The patient then said that he/she had moved address, and now lived in Hackney, a neighbouring borough. The patient had had to come to the surgery by minicab, hence the delay in getting to the surgery. The patient said: ‘This really does not work for me. I’ve moved but did not want to change doctors, but this does not work.’ What the patient meant was that getting medical care under his/her present circumstances was difficult, due to the distance.   In fact, it did not work.

I told the patient that this had been my experience: looking after patients at a distance becomes more complex, and often unworkable. It works fine for patients who are well and do not need medical attention, but does not work if the patient becomes ill. I told the patient I was about to speak to a group about this problem, and the fact that the Health Bill was seeking to abolish practice boundaries and allow patients to register with a GP of their choice, regardless of where they lived. The patient said this did not make sense. I agreed. I encouraged the patient to find a local GP.

The next day the results of the urine test came back: the patient did in fact have a urinary tract infection, and the antibiotics she had should have treated the infection. I spoke with the patient on the phone; there had been an improvement. I warned him/her that if this recurred, he/she would need further investigation.

This is a simple story. It illustrates the problem well. The patient had delayed registering with a local GP because there were problems (limited choice given his/her new address). When he/she became ill and needed to see the GP, the practical issues became evident.

A core part of our work is looking after people who are sick. Sick people are less mobile. There is no getting away from this very basic fact. That is why patients need a primary care practice which is local, not distant. Distance is a barrier to care.

Thoughts on the GPC-DoH Agreement on GP Practice Boundary Issue


News reached us just under 2 weeks ago the GPC and Department of Health had reached an agreement about the issue of practice boundaries. There are two provisions: 1. practices will be encouraged to reach an agreement with their PCTs about an ‘outer’ practice boundary which will allow patients to remain registered should they move outside the ‘inner’ practice boundary, ‘where clinically appropriate’. 2. There will be two or three city pilots for commuter patients to register with a participating practice close to their work, and an independent evaluation will be carried out.

I have campaigned on this issue, having seen the orignal proposed policy (patients in England being able to register with the GP practice of their choice, ‘anywhere in England’) as quite mad and unworkable. I am pleased with this outcome, and the GPC is to be commended for having negoiated this. As should the GP body that resisted the proposal.

This current arrangement implicitly recognises that general practice is a local and community-based technology, which the previous proposal (which all 3 major parties subscribed to) ignored entirely. Even the commuters will need to register with a practice not far from their work.

Of course, there are significant practicalities which will need to be addressed: who pays for the costs of the commuters? How is this money transferred? How does this fit in with Clinical Commissioning  Groups and commissioning? Certain areas, such as the Isle of Dogs in Tower Hamlets which hosts Canary Wharf and a commuter population of about 100,00, will be affected very significantly. And then, what happens when the commuter is ill at home, how does he or she access local help, especially if the illness needs more than one GP encounter?

It is absolutely vital that the ‘independent evaluation organised by the Department [of Health]’ be truly independent and honest and rigorous (that is, not on the model of the so-called ‘consultation’ on this issue carried out by the DoH in March-July 2010 which was PR exercise which misled the respondents and Parliament).

It must be said that the inner and outer boundary model is something that some practices have had in place for many years already. Under the agreed provision, practices will have the option of having an ‘outer boundary’ and clearly they will have to choose a boundary that allows them to deliver a functioning service. That is well and good.

It is very important that the politicians and DoH do not attempt to resurrect this mad idea in the future, and that we make it clear to everyone that UK general practice is at its core a locally based technology which simply does not work on the same model as McDonald’s and mobile telephones. It may be possible to make exceptions in certain circumstances (such as the commuter), but this is an exception rather than the thin edge of the wedge.

A large wooden stake needs to be driven firmly into the heart of this vampire. That is why I will continue to write to MPs and continue to write about this issue because I have not covered all the ground yet.