Troubling Patients in Troubling Times: workshop at RCGP

04/11/2011

I’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.


My email to Peer, via 38 Degrees

06/10/2011

 

Dear Baroness Stedman-Scott,

 

I am a GP in Tower Hamlets. I have grave concerns about the Government’s Health & Social Care Bill. You will be aware of the concerns about various ingredients of this bill. I have quite a lot of experience relating to one of the Bill’s proposals: to abolish GP practice boundaries. I have resorted to writing a blog about this issue, and emailing MPs in the House of Commons. This proposal sounds like a good idea, and all 3 major parties support this policy. However, to most GPs it seems madness: this because of the nature of general practice and how it works. This proposal is simply unworkable: it will increase inefficiencies and at times be dangerous, it will cost more, and it will not deliver what it claims to be aiming for, patient choice. How intelligent people can actually champion such an idea is beyond me; but of course there is probably an underlying, unstated/hidden agenda. For a summary of the problem, with links to back my allegations, see

http://bit.ly/pMWLNb

If the Secretary of State for Health can get it so wrong for this particular issue, I have little faith in his competence and methodology to deliver a credible solution to the many challenges facing us all in the NHS. I hope the House of Lords scrutinise this Bill with care and resist proposals which lack an evidence base and will undermine the NHS.

 

Yours sincerely,

 

George Farrelly

Write to a Peer:      http://bit.ly/qLhQhM

 


An early morning email to Lib Dem MPs

15/09/2011

It’s me again, I’m afraid. I thought I better warn you about what almost certainly lies ahead with respect to the issue of GP practice boundaries.

I have never felt that this added up: from a practical point of view, it just does not make sense at all. I thought these politicians and DoH planners were just grotesquely stupid.

The reality is almost certainly one of deceipt and corruption, with the rest of politicians either complicit or just naïve.

A member of the public left a comment on my blog yesterday; he had joined up the dots, and at the end he mentioned the ‘virgin assura system of connected health centres across the UK’. I was unaware that such a thing existed. I had hypothesised that such a thing would exist in the future and that this was why they wanted to abolish GP proactice boundaries. But I woke this morning at 4am and thought I would just check, and, lo and behold, I found this.

I suggest you have a look at the leaflet that the DoH and New Labour produced  to accompany the so-called ‘Consultation’ on the question of GP boundaries in March 2010. Notice that nowhere in the leaflet, and nowhere in the larger consultation documentation, do they say: ‘and you could join the Virgin Assura system of connected health centres’, but this is in effect what the abolishing of GP practice boundaries will do. That is why they want to do it, otherwise it just does not make sense. All this talk of ‘patient choice’ is just camouflage. Just have a look at Virgin’s website, and then look at the DoH leaflet. The leaflet is a promotion of what Virgin is offering. And note that the proponents of this policy use the results of the ‘Consultation’ as evidence that the English public want this. But the ‘Consultation’ was pitched in such a way so as to produce this result, the questions are skewed in this direction.

There is really a lot more to this, and it will come out in the open in due course, I am sure. Because the media (who up to now have been crap about this issue, completely uninterested) is going to wake up soon and start shining a light on this.

Why am I writing to you at 4am? Because you people are heading off to your conference and you have been told by your leader that you cannot mention the NHS. And yet, shouldn’t you be talking about this?? Nick Clegg may have some sort of future as a Tory MP, but the Lib Dem party will have had it entirely when it becomes clear that you have been duped and used, along with the English public, as the NHS is swallowed up the the piranhas. Once they pass the law, there will be no going back.

I just thought I had better warn you.

And now I’ll have some breakfast, and then go to the surgery and see some patients, all of whom live local to the practice.

Best wishes,

George


Comment by member of the public on the issue of GP boundaries

14/09/2011

A member of the public has posted this comment on my Home Page:

Dear Dr Farrelly,

I will admit you have changed my mind on the subject of the need to register locally. I specifically think the examples you give bring home the reality of boundary changes in many situations.

If the boundary registration was removed, does the new system say you must accept all who try to register with you? Or can you refuse applicants on the basis of there distance from your surgery? I would guess that you must be able to say no to some patients in the new system otherwise you could end up with all of London registered with one GP service that has a “good” reputation (hypothetically)

Also if the new system was introduced and GPs had the option of refusing certain patients would this lead to private providers “cherry picking” patients. For example only registering young working professions leaving you with the more complicated and expensive patients such as haemophiliacs etc.

I ask as I travel within the UK I was originally drawn to the idea of open boundaries and the virgin assura system of connected health centres across the UK but I am now concerned that such an action may be of mild benefit to me but lead to a great dis-benefit for the majority of patients.

Anyway thank you for a informative website

*

My reply:

Thank you for your thoughtful and generous comment. Will we be forced to accept all comers if boundaries are abolished? Clearly, this would be a recipe for disaster. And yet, if people are not able to register with the GP practice of their choice, ‘anywhere in England’, they will rightly feel aggrieved, having been promised this. The practicalities have not appeared in public; I imagine there are a number of middle-ranking people at the DoH sweating to somehow square the circle. Cherry picking: yes, this will appear in different ways. You are, I think, right that people like you will benefit but many others will not, and English (not Scottish or Welsh for the moment) general practice will suffer.
Watch this space. The anomalies and absurdities will emerge in time. This is a scandal in search of an audience.


The Department of Health’s response to my concerns about GP practice boundaries

11/09/2011

In January 2011 I began emailing MPs, one letter at a time (all the A’s, then the B’s, etc); & I copied the health ministers in as well. I then received an email from the DoH; a long disquisition on the White Paper, and the Bill which intended to ‘modernise’ the NHS. It said nothing whatsoever about practice boundaries. So I emailed the ministers, saying, among other things, this: ‘…your response is not really a response to my concerns at all. It is as though I had asked how to get to Bristol
from London by train and you had sent me a recipe for a cheese omelette.’

A few hours later I received this email:

21/2/11

Dear Dr Farrelly,

Thank you for your email of 31 January to Anne Milton about GP practice boundaries. I have been asked to reply.

The Government’s proposals for greater choice of GP practice are designed to reflect the central importance of general practice in providing continuity of care for those on their registered lists. The Department of Health knows that the majority of people are happy or very happy with their local GP practice and with the continuity of care that it provides. But the Department also knows that a significant minority have no choice but to register with a practice that they then rarely use because of difficulties of access, or because it does not provide a responsive service. Some of these people rely instead on using a mix of Accident and Emergency services, walk-in centres and other urgent care services. The Department’s aim is to ensure that everyone is able to register with a practice that provides genuine continuity of care.

The Department does not envisage that many patients will want to want to choose a GP practice a long way from where they live. There will clearly be many cases, particularly for people with complex health problems, where it makes obvious sense to choose a nearby GP practice. The Government thinks it wrong, however, to prevent people from registering with a practice (for example, one near to their place of work) where they have made an informed decision that this will provide the best and most responsive service for them.

On 4 March 2010, the Department of Health initiated a consultation to seek people’s views on proposals to abolish GP practice boundaries so that people can register with a GP practice of their choice. The consultation closed on 2 July and attracted over 5,000 responses from members of the public and clinicians, which shows how important an issue this is to so many people, patients and NHS staff.

The responses show that over three-quarters of the public want to be able to choose their GP practice and do not want this ability constrained by practice boundaries. Many GPs and NHS colleagues have raised issues about how opening up choice will work in practice, and the Department of Health is working through these issues with professional and patient groups and with the NHS. The Department published a summary of the responses on 18 October 2010, which is available on its website at:

www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_120283

The Department plans to set out a more detailed plan of action shortly that will look at the arrangements that the NHS will need to put in place over then next year. The Government is confident, however, that it can do this in a way that not only preserves the strengths of general practice and registered lists, but enables everyone (not just the majority) to benefit from these strengths.

I hope this reply is helpful.

Yours sincerely,

X

*

My Response (copied to the health ministers, and members of the Health Select Committee):

Dear X,

Thank you for your response to my concerns. I would have answered sooner but have had to keep up with the day/evening/weekend job. I am afraid that you are up against a technical problem which cannot be eliminated by wishful thinking or sound bites. By ‘technical’ I mean things like gravity, not being able to be in 2 places at the same time, the fact that it takes time to get from A to B, that there are limits to how many travellers can (safely) fit on a plane, that if you try to walk across the Channel to get to France you will sink in the water. Your bosses and the politicians have just ignored the technical aspects of their proposal. Just as technical aspects were ignored or wished away in the invasion of Iraq. The trouble, in the real world, is that the technical persists.Would you want to work in a skyscaper that was built by dreamers? Perhaps designed by dreamers, yes, but then cleared by feet-on-the-ground structural engineers and built by professionals. May I suggest you read The Checklist Manifesto by Atul Gawande (a surgeon); pages 70-1 if you are in a real hurry.

In 1991 when my wife and I were interviewed by a panel in order to take on the responsibility of our present practice, one of the questions we were asked was, ‘What are you going to do about the outliers on the list?’ Outliers were patients who lived outside the practice area (some at a fair distance). Because at that time it was felt that to have patients living at a distance from the practice was ‘poor practice’, that it led to poor care. This was for technical reasons. We explained how we would deal with
this. We had to write to a number of patients who lived at some distance from the practice and ask them to get a local GP. They would have preferred to stay on the list, for their own reasons, that would have been their ‘choice’. It took extra work to do this, why do it?

The technical aspects which pertained then have not changed, they are pretty much the same. You cannot escape from that, that’s just the way the world works. The Department of Health and politicians have alluded to practice areas as an outmoded irritation, ‘constraining choice’. I assure you, there are perfectly sound, practical, reasons for ‘practice boundaries’. I have learned this over my 20 years in Bow. I see it every day.

Why am I spending time on a Saturday night writing to you, spending time with this issue? I would much prefer to be reading a book, watching a film, seeing friends. I am spending time on this because there are real reasons why what your bosses and the politicians are planning will lead to an undermining of good quality British general practice. And this is tragic. If we end up, 10 years from now, with a US-like model of primary care, that will be an incredibly retrograde step.

I do not have the time right now to respond to each of the points in your email. I will do so when I have time. I am not persuaded by your arguments. I certainly accept that we should aspire to providing good quality general practice to the whole population, but your bosses’ plan will not achieve this. The so-called Consultation which you allude to I view as a dishonest PR exercise. I hope to get the time to show why. Perhaps check my blog in a month or so.

Perhaps you truly believe what ‘The Department’ are doing. It may be that you think it is a bit crazy, but you have to pay the mortgage. I would not blame you if that is your position.

Best wishes,

George


Email exchange with MP on GP practice boundaries

11/09/2011

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


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


You need to keep shouting and protesting

03/09/2011

Just received this comment to the Home Page, which I think is most eloquent:

‘I have been  married to my husband, a GP for 15 years. We live in Cambridgeshire with our three children. I cannot believe the way in which the profession is being treated, its terrible. I have watched a dedicated, excellent doctor slowly become more pressured, stressed and withdrawn due to the hassle that is being created by this government and their reforms. The hours are increasing to sometimes 90 hours per week, the nature of the job is changing and the finances are being withdrawn. I lecture and work in America at times and see the difficulties with the medical system there. The poor are discriminated against and now due to the recession even the more affluent of folk have stopped paying into health plans as they cannot afford it. They pray that they do not become sick! Is this what we want here in the UK because this is where we are heading. We have become so fed up with the NHS that we have decided to move to Canada in November. We have had enough of the battles and the stress. The NHS is losing a fantastic doctor in the prime of his career. We are one of many! You need to keep shouting and protesting because this government does not have a clue about the implications.’


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.’

 


The public are having to protect their institutions from the people in charge

14/08/2011

Something has gone seriously wrong if the citizens have to protect public institutions from the people in authority whose responsibility it is to safeguard those institutions.

A most unsettling situation: the people at the frontline have to protest to the politicians & policy makers whose responsibility it is to optimise the functioning of the system. What do you do if these politicians and policy makers propose policies which undermine and dismantle the system, while telling you they are making it better?

For information on how to write to your MP, click
here.

It’s better than having to go out and riot. I hope.

(One example, see my email exchange with ‘Andrew Lansley’)