I received the following email a few months ago, in response to one of my emails to MPs. I have been emailing one alphabetical letter at a time.
Dear Dr Farrelly,
Thank you for emailing me. I congratulate you on your efforts to contact all MPs and taking the trouble to make sure that you semi-personalise the email.
I will read the attachments you have sent.
I must say that I do have some sympathy with the idea of free registration. I had an excellent GP in Exeter* who I was with from the age of 19 when I went to University. It seems strange that I could not remain with that GP when I only live 40mins away in Lyme Regis.
I would be interested in your thoughts on this.
Best wishes,
X
* [This MP did not go to university in Exeter, nor lives in Lyme Regis, and is not the MP for that area of the country; I have changed the names but the geographical distance comparable. This MP wrote in a good-natured way and was not expecting me to make this public and discuss its contents in public, and I am maintaining her/his anonymity. But I am making the contents public because I think it illustrates some important issues. I reproduce below my response.]
*
Dear X,
Thank you for responding to my email some months ago. I replied briefly at the time, and am now sending a more complete reply. I am making this public on my blog, without divulging your identity.
In your email you say that you would have liked to remain registered with the excellent GP in Exeter and that ‘it seems strange that I could not remain with that GP when I only live 40mins away’. I too have patients who move away and would like to remain registered with me. What I say to them is this: for me to offer you good care it is essential that you can get to me easily, and that I can get to you easily. With you living 40 minutes away by car, it makes this impractical. I know that it is difficult for you and that you have built up a relationship with us, but in the interests of safety and good practice I have to insist that you get a local GP near where you live.
Patients usually then acknowledge there are real practical issues, and get registered locally.
But I will illustrate this further with an example. Let us say you develop pyelonephritis; this is a kidney infection which needs urgent assessment (physical examination, urine sample) and treatment with high dose antibiotics, and often admission to hospital. You would feel pretty ill, and might well be too ill to travel to Exeter, and I would certainly not be able to take 40 minutes to drive to Lyme Regis to assess you (80 minutes round trip, with perhaps 15-20 minutes to assess you). Now it is possible to treat pyelonephritis at home but it needs close monitoring and admission if you get worse (for a variety of reasons we would prefer to manage you at home, but this is not without risk). This is not something that can be managed over the telephone. We might well want to see you again the following day. You will understand all this cannot happen at a 40 minute’s drive distance. It simply does not work.
This is an example of an acute, serious illness (this can happen to anyone, no matter how healthy). But there are a variety of other conditions which might require regular visits to the surgery, such as hypertension: initial screening to identify the problem (are you likely to answer an invitation to have a vascular risk assessment if you have to drive 80 minutes for this, and you feel perfectly well? If you lived nearby you could drop in on your way home from work, or fit it in on a day off when you are doing some gardening); repeated visits to get your blood pressure under control; once
stable, 2 visits a year for assessment.
And if you have need of a district nurse, the team attached to your GP surgery in Exeter will not be able to visit you (at least not without a drain on their [limited]resources in terms of time). And who is going to pay for you? The PCT covering Exeter is likely to not cover Lyme Regis. So if you have a hernia repair, will this come out of Exeter’s budget (which will have been worked out for that area’s population), in which case this will be taking a (limited) resource away from the Exeter health economy; or do you set up a layer of bureaucracy so that ‘money follows the patient’? And to have your stitches removed 1 week after your hernia repair, do you drive 80 minutes for this?
One other possibly hidden systemic impact of this: all practices have a capacity limit. They can look after a given number of patients well, and if the numbers exceed this at some point quality will decline. So your Exeter GP surgery will not have unlimited capacity. If you, 40 minutes away and fit and healthy, are registered at his practice, it is possible that a person living in the GP’s practice area will not be able to register. That is, you are taking up a place that otherwise would have been occupied by a local.
(This is the way it is with our practice in Tower Hamlets: we keep the list size at 3,520 give or take; as people leave the area and the list, other local people register; if we had non-local people on our list this would be at the expense of local residents; so in our case, it does not make any sense whatsoever to register people who live at a distance from the practice and we cannot look after properly, when local demand exceeds supply).
My wife is a member of the recently created Tower Hamlets Clinical Commissioning Group. She points out that the proposal to abolish practice boundaries conflicts with the proposal the create Health and Wellbeing Boards which are geographically based and are meant to feed into commissioning for the needs of the local population. But if we have a significant number of non-Tower Hamlets residents registered with us (commuters to Canary Wharf number ~100,000, local resident population ~30,000), where do they fit in? They will be using local resources for non-local people. And if our residents register in other jurisdictions, how are their needs assessed and commissioned for?
I could go on, and on. But I think you get the picture. Good quality general practice is a very complex technology. As a system it is local; the system works as integrated local network. To ask it to perform the same service for an expanded territory is foolhardy. It simply does not work.
In the coming months it is likely that there will be a battle between the government and the the GPC on this; then there will be anger by GPs over this. And the reason GPs will be angry is because we are being asked (forced) to do something which is unworkable, and will impact negatively on our work.
Anyway, I must stop there. Again, many thanks for taking the time to respond to my original email and in taking an interest.
I wish you all the best with your work as an MP, and life in general,
George
*
For my email exchange with ‘Andrew Lansley’, click here
Posted by gpprotest 
Troubling Patients in Troubling Times: workshop at RCGP
04/11/2011I’m just back from a day’s workshop at the Royal College of General Practitioners. The title: Troubling Patients in Troubling Times. This was a joint venture by the APP (Association for Psychoanalytic Psychotherapy in the NHS), The Balint Society, and the Royal College of General Practitioners. The participants were psychologists, psychotherapists, counsellors, GPs.
As is often the case with things named by psychotherapists, the title is a bit ambiguous, thought provoking. It was not about professionals troubling patients in troubling times, which is one possible reading. It was about, in part, patients troubled in these troubling times. Patients who bring their distress to the GP, the psychologist, the counsellor, the psychotherapist. ‘Troubling Times’: of course, this refers to the current context, with cuts in services, more pressure on the remaining services, with ‘reforms’ which are wolves clothed as lambs. But in some ways, all times are Troubling; but perhaps some more than others.
The introductory talk was given by Jan Wiener, a psychotherapist with many years experience of working in the primary care setting in partnership with GPs. Her talk, which I will not summarise, was entitled ‘Mindlessness in Troubled Times’. The title, I think, is enough to give pause for reflection.
We had a series of GP consultation vignettes, acted by the organising committee members which captured a wide variety of common primary care dilemmas and challenges. Some were troubling, some gave us to laugh.
Then small group work, a Balint group watched by the wider group, a small group Balint case discussion, and then a plenary session.
Many themes emerged. The ones I recall at this moment: with services being cut, there are people with significant distress who are then left without an important support; the importance of the work of psychologists/counsellors/psychotherapists; the central role of the GP; the importance of collaboration, communication; the (occasional, ? frequent) breakdown in communication between hospital and primary care; the mindlessness of some ‘reforms’, some protocols; a feeling of powerlessness in the face of the mindlessness (who do you take your concerns to? if your manager does not understand the work you do, what do you do?; and so on).
There was a sense that people had significant grievances which they needed to address to those in charge. I encouraged them to find out who these people were, to speak out, to protest. A few asked me about this blog. I gave them some advice about starting their own blogs. I wish them all the best.
One young GP voiced this: the bewilderment at the government asking us GPs to do things that make our job more difficult. Ah, yes, a familiar story.