A helpful criterion from physicist Richard Feynman

02/07/2011

“For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.”

This morning I read an article in the New York Review of Books: Freemon Dyson reviewing two books about the physicist Richard Feynman. Dyson relates one episode towards the end of Feynman’s life. Feynman was invited to be part of the NASA commission investigating the space shuttle Challenger disaster of 1986 (the shuttle broke apart a minute after take off, resulting in the death of the 7 astronauts on board).  Feynman was ill with cancer at the time, and did not have long to live: ‘He undertook it because he felt an obligation to find the root causes of the disaster and to speak plainly to the public about his findings. He went to Washington and found what he had expected at the heart of the tragedy: a bureaucratic hierarchy with two groups of people, the engineers and the managers, who lived in separate worlds and did not communicate with each other. The engineers lived in the world of technical facts; the managers lived in the world of political dogmas.’ Feynman found that these two groups had very different views of the levels of risk: the engineers estimated the risk to be one disaster in every 100 missions; the managers estimated the risk as one disaster in 100,000 missions. There were two main causes of the disaster: a probable direct technical cause (a rubber O-ring seal which malfunctioned at cold temperatures), and a cultural cause. ‘The political dogma of the managers, declaring risks to be a thousand times smaller than the technical facts would indicate, was the cultural cause of the disaster. The political dogma arose from a long history of public statements by political leaders that the Shuttle was safe and reliable. Feynman ended his account with the famous declaration:

“For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.”‘

I am very happy to have found this sentence for it helps to clarify the situation which confronts us with the issue of GP practice boundaries (and of course the many other complex issues surrounding the NHS, and the so-called ‘reforms’).

Can we please allow reality to take precedence over public relations? Can the politicians and DH please do a sensible and honest and public RISK ASSESSMENT of the complex technology that is UK general practice, and the function of practice boundaries? And of the technical problems which come into play when people live at a distance from their registered GPs? 

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New York Review of Books article  (unfortunately, you cannot read whole article without a subscription)

Challenger Disaster  (Wikipedia; a salutary read)


My email to MPs, surnames beginning I & J

26/06/2011

 

Dear Alan, Andrew, Bernard, Cathy, Dan, David, Diana, Eric, Gareth, Glenda, Graham, Helen, Huw, Jo, Kevan, Marcus, Margot, Sajid,Sian, Stewart, Susan, and Tessa,

Summary: All 3 major political parties are in favour of dropping GP practice boundaries and allowing people in England to register with GP practice of their choice, anywhere in England. Sounds like a good idea; but if you understand how general practice works and think through the issue, it is filled with problems: to look after a patient who lives at a distance from the practice leads to poorer care for the patient, increased use of resources by the practice, and it is sometimes unsafe. There are other risks as well; & it will cost more. The Government is pressing ahead with this. The recent LMC GP conference voted overwhelmingly to resist this policy. So this could become a battleground in the coming months. How might this play out? If a light is shone on this issue, who will come out looking stupid? Or is there an unstated aim with this, part of what some have called ‘the plot against the NHS’?

If this does not interest you, click delete.

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I am a GP in Tower Hamlets. When my wife and I were interviewed in 1991 to take over a GP practice that had become vacant, we were asked what we were going to the about the ‘outliers’, those who lived outside the practice boundaries. It was then considered bad practice to have patients living at a distance from the practice, and good practice to have patients living near the practice so as to have easy access to primary care services, and to be able to link in to local integrated services when needed. Over the years we have had a lot of experience with this, and it is very clear that the quality of health care provided to a patient begins to unravel if they move away and continue to use us as their GPs (concrete examples offered through links, see below). We have to gently but firmly ask them to get a local GP. In essence, we have, de facto, carried out a 20 year pilot study on the pros and cons of practice boundaries.

So you can understand that when politicians began saying that they wanted to do away with practice boundaries a few years ago, we were bewildered. At first, I thought it was a parody. But, no, they pressed on, with Andrew Lansley taunting Alan Johnson (when he was Health Secretary) for dragging his heels over this; then Andy Burnham announcing in September 2009 that Labour intended to do away with practice boundaries within a year, and launching the so-called ‘consultation’ just before the General Election in 2010, and then Andrew Lansley of course offering it in the White Paper, and then the Health and Social Care Bill (I must say, I have tried to find where it is mentioned in the Bill and I cannot find it; in fact, the Bill is to me, as a member of the public, unreadable, impossible to understand).

From my point of view as a GP trying to provide quality general practice services to my local community, this proposal is quite mad and unworkable, and will lead to all sorts of unintended consequences which will undermine primary care services in England, cost more, and be less efficient at a time when we are being asked to cut costs and be more efficient.

So in March 2010 I emailed Andrew Lansley about this. Of course, he ignored me as he had other issues on his mind. But I pressed on, and did in the end have an email exchange with his Chief of Staff (for full text, see link below). What became evident is that Andrew Lansley and his team had not performed even a most basic feasibility study on this issue, to identify the potential risks.

At the same time, the Government (Labour) and Department of Health launched their so-called ‘consultation’ on this issue. I read the documentation with some care and was startled to find that the DoH failed to do a risk assessment. In essence, the documentation is a PR exercise gently, subtly (and not-so-subtly) nudging the reader in the direction of saying Yes to this policy. Even the questions asked in the Questionnaire were phrased in a way to elicit a ‘Yes’ vote. It was like selling a house with glossy (air brushed) photos but no structural surveyor’s report. And it reminded me of previous (New) Labour ‘dodgy’ dossiers. And the Government/DoH response to the consultation was to press on with the policy, citing the fact the majority of the 3,220 responses from members of the public were in favour of opening up choice in this way. It seems strange that 100% of members of the public were not in favour, as the way the DoH presented this policy there seemed to be no adverse costs, no adverse consequences, just increased choice. The DoH stated that they had received responses from other ‘stakeholders’, such as the BMA and RCGP (Royal College of General Practitioners) but they did not go into any detail whatsoever about whatever criticisms these responses might have contained, nor did they offer links to the documents. I offer a link to the RCGP response below.

A year ago, at a large meeting of Tower Hamlets GPs assembled to discuss Andrew Lansley’s White Paper, I asked about the issue of abolishing GP boundaries. I was told that, yes, it was a bonkers idea, but the fact that all three major political parties favour it meant that it was pointless to oppose it. At the time this did not seem to be a very good reason to go along with a stupid idea. But our local leadership had different concerns (all the issues that led to the significant opposition to the Bill, and on to the so-called ‘listening exercise’). So I decided something had to be done so I started my blog, and called it onegpprotest. I have been writing to MPs, one letter at a time. It is a slow business, loading the email addresses one at a time, composing the email (they are all different, but with substantially the same message). Some MPs have let me know that there is a convention whereby MPs only deal with issues brought to them by their own constituents, so my email to them is out of place. Well, I am not writing to you as a constituent, but as a Lobbyist. Who is funding me? Nobody. I am paying the costs of the blog, the (considerable) time of assembling and disemminating the evidence. I would prefer to be spending my time in other ways, but I think thatUKgeneral practice is a very valuable national resource, and do not want the political class to flush it down the toilet. (There are no doubt GP practices that do not offer good quality general practice, and effective ways should be found to raise standards generally; this proposed policy is not a solution to this problem). The bottom line is this: were my practice to adopt this policy the service we would provide would be poorer, and we would be able to look after fewer actual local residents (as their place would be taken by people living at a distance from the practice). So we will simply refuse to follow this policy, and make it quite clear why. And if the DoH tries to shut us down, I will fight it, but resign if needs be.

Now I was very pleased that when Clare Gerada became Chair of the RCGP she was more vocal and robust about the issue of practice areas. And pleased when I heard that at the recent LMC conference this issue was debated (nobody could be found to support it, which apparently is very unusual) and the GPC was charged with putting up a ‘staunch’ resistance to this policy in future negotiations with the DoH. The headline in Pulse reads: LMC Leaders Declare War Over Practice Boundaries.

So you can see that this issue, which currently has a very low profile and on the face of it is a rather mundane, non-sexy issue, could become an issue which will get more attention. And if light is shone on this issue, questions may begin to be asked; and when that happens whose reputations will be tarnished? Why is it that Andrew Lansley did not do a feasibility study before suggesting this policy? Why did the DoH design the ‘consultation’ in this biased way? How would Andy Burnham’s promises actually work in the real world? Why did nobody in the political class raise concerns about this issue which, after all, affects every one of their constituents?

You might say, ‘But we’re offering the English people choice…’; yes, but what is that ‘choice’? You need to ‘model’ it (in the sense of showing how it works in practice; really works in the actual world, not how you would like it to work). Most of the responses I receive to my challenges involve bringing out the ‘Choice’ word as though it is the Ace of Spades trumping all. But almost without fail, the people have not modelled it; they allude to ‘some problems which will be sorted out…’ or some similar vague gloss.

Finally, some suggest that the reason for this policy is not primarily to offer English residents choice, but to open up the system of primary care to large provider organisations on the American HMO model. In other words, by essentially de-regulating English general practice (the practice area or boundary acts as a sort of regulator), an organisation like, say, Virgin can offer primary care services which are non-geographically limited. I can register with ‘Virgin Health’ based in the city centre; most of the people who register with such a practice will be essentially healthy, mobile people with few significant chronic illnesses. Yes, it will be practical and user-friendly for these people, but as a total system of national primary care things will suffer. But of course, nobody is suggesting this, or suggesting that we debate it. And this is why some people call it a ‘plot’: it is covert. The people who subscribe to this view say that the DoH and planners dress these policies up and use the words ‘choice’, ‘modernisation’, ‘reform’ to set out a series of steps which move in a certain (unstated) direction. If this turned out to have some truth to it, then the citizens of this country might have reason to be very angry.

 

Links for further information:

The problem of Choose Your GP Practice in a Nutshell      

 My email exhange with ‘Andrew Lansley’   

Looking after patients at a distance, concrete examples:             

Patients at a distance & another example from everyday work  

My email exchange with The King’s Fund                

My email to the Patient’s Association 

RCGP Response to Choose Your GP ‘consultation’

LMC Leaders Declare War Over Practice Boundaries 

‘The Plot Against the NHS’:         This & This

Best wishes,

George

 


My email to Patients Association about bid to abolish practice boundaries

12/06/2011

 

Dear Vanessa Bourne, Celia Grandison-Markey, and The Patients Association,

I am a GP in Tower Hamlets. I heard the radio piece on GP practice boundaries on the Today Programme last Wednesday morning as I was driving into work. I have a particular concern about this issue.

My wife and I have been GPs in a small practice in Tower Hamlets since 1991. When we were interviewed to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ (patients living outside the practice area). It was then considered poor practice to have patients living at a distance from the practice, and good practice to serve a community of people who lived close enough to the practice to maximise access and integration with other services. We have in fact attempted to serve such a community and are pretty firm with patients who move away (as is common in inner city London practices, there is a fair turnover of patients). We have had quite a lot of experience with patients who continue to use us as their GPs even after they have moved away, and it has only confirmed us in the conviction that is not possible to deliver good quality care to people who live at a distance from the practice. The problems are directly proportional to the distance from the practice. Of course there are individual exceptions, but in general patients do not access us appropriately (they delay seeing us; they save up lots of problems which we cannot deal with in a single appointment), or they expect us to deal with problems over the phone which really require a face-to-face encounter, corners are cut, and sometimes it is actually unsafe. And on and on.

Then there is another problem, and it is one of capacity. We are currently unable to register all patients living within our practice area who choose to register with us. Demand exceeds capacity. If we exceed our capacity, then the quality of the service we offer our patients is compromised and quite quickly things become unsafe. So we have had to take the decision, in breach of the 2004 GP contract, to set a limit on our list size. As people move away, we can register more patients, trying to maintain a list size of 3,520 patients.

Now I sympathise with your wish to meet patients’ needs. There really is a problem for some to get registered with a practice that offers a ‘good enough’ service. But this policy of abolishing practice boundaries will not, as a system, solve the problem. Sure, there may be a few patients who will benefit, but the overall effect will be negative. And this for the two general reasons outlined above: 1. the complexity of providing good quality general practice and how distance impacts negatively (there are a host of other issues such as the problems with commissioning services with a budget that is for a local population, and so on); 2. the problem of capacity. In fact, this second aspect of the proposed policy makes the policy unworkable. What I mean is this: most GPs (if not all) are currently working at full capacity. If more than a handful of extra patients wish to register with a popular practice, it will impact on that practice. All practices will, at some point, reach their capacity. If they exceed that capacity, the service will suffer. If patients outside the practice area displace local residents, this will be at the local residents’ expense.

To give you an example from Tower Hamlets: CanaryWharf has a commuter population of approximately 100,000. The resident population of the Isle of Dogs is about 30,000 and is served mainly by 4 practices. If 10% of the commuters to CanaryWharf ‘choose’ to register locally, it would have a very significant impact on the local GP services.

For the reasons I have sketched above, our practice will be unable to provide services to patients outside our current practice area. We would simply refuse to do it and make it clear why. It would be perverse to look after patients who live outside our area (which we feel is at best inefficient, at worse unsafe), and have fewer places on the list for local residents.

I am afraid the politicians have made promises which they simply cannot keep. Blame them, not the GPs. Many of us are doing a very difficult job as best we can. When we are then landed with policies which make our job even more difficult and which are very poorly thought out, it is very demoralising.

Vanessa Bourne said in her contribution on the Today Programme, ‘Here we have something that has nothing to do with the patient, only to do with their address.’ I would challenge this and say that our practice area allows us to serve a local community with maximal efficiency and efficacy, and this has everything to do with the patient. The reality is that the vast majority of patient-practice transactions that take place are local ones.

So I feel that what is actually needed is attention given to raising the standards of practices in general (where this is needed), so that people do not have to travel to access good general practice. There may in some cases be an argument for some people registering with a practice near their work (but what happens when they become unwell?), but this is not the same as allowing the whole English population to register with the practice of their choice anywhere in England.

I started a protest blog about this issue several months ago, and for a time it felt mine was a lone voice. Most people were taken up with other aspects of the Health Bill (and rightly so). I was encouraged to see that the LMC conference a few days debated this issue and it would appear that the GPC is going to fight this pretty robustly in the coming months.

It is important that you are aware of the complex reasons why practice boundaries exist, and that they are not simply arbitrary lines on a map meant to deny people choice. That is not to say that there not people who experience them, understandably, as a significant frustration.

I almost forgot: I would strongly recommend you get hold of a book called The Plot Against the NHS, by Leys and Player. It is an analysis of the behind the scenes goings on in health policy planning in the past 10 years of so. It does not address this issue of practice boundaries; but it may well be that the politicians’ and DH’s reasons for proposing this policy is in order to open up primary care to large private care organisations on the Kaiser Permanente model. If that is the case, then they ought to be honest about it. And your organisation would do well to understand this so you can plan your strategy.

I wish you well in your work.

Best wishes,

George

[July 2014: I never received a reply to this email]

www.onegpprotest.org

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Examples of problems  (& this)when patients live at a distance from the practice:

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Why did Andrew Lansley not think this through? I don’t know; neither did Andy Burnham (despite what the DH says about the so-called ‘Choose Your GP Consultation’ from a year ago). Neither of them have examined with any rigour the consequences of ‘choice’ in this case. See my email exchange with ‘Andrew Lansley’.

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For the RCGP’s response to the Government ‘consultation’ on practice boundaries.

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For my email exchange with the King’s Fund.

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The Plot Against the NHS

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Article on practice boundaries with respect to the LMC Conference


My email to MPs, surname beginning with H; copy to Health Select Committee

08/06/2011

 

I am writing to all MPs, one letter at a time. Each letter is different. You are the H’s.

Quick summary: the proposal to abolish GP practice boundaries and give people more choice sounds good at first sight; but the practicalities mean that patients living at a distance from the practice receive poorer care; it is more resource consuming for the practice; and in some cases it is unsafe. Read on if interested; if not, press delete.

All three major political parties share the idea that abolishing GP practice boundaries is desirable. At some point in the future this will be exposed as a very stupid idea, especially when they try to implement it. Do you want to know why?

My wife and I have worked in a small practice in Tower Hamlets for 20 years. When we were interviewed to take this practice over when it became vacant in 1991, we were asked what we were going to do about the ‘outliers’ (people living outside the practice area). At that time, it was thought to be bad practice to have patients living at a distance from the surgery, and good practice to serve a community living close to the surgery. We have a relatively high turnover of patients and people move out of the area; and because we are popular, many of our patients try to continue using us as their GPs even after they have moved away. So we have had a lot of experience of trying to look after patients who live at a distance from the practice: we have acted in a way as a pilot site for this proposal.

And we can say that it is quite disastrous: patients don’t consult us appropriately: they leave things too late, or they don’t consult at all (and important things are neglected); or they save things up so they only make one trip and they then over-run their 10 minute appointment considerably; and then there is the problem of local services (which they are unable to engage with), and on and on. So to us this proposal is really quite mad.

In addition, it is unworkable because GPs are currently at full capacity; how are the popular GPs going to register more patients? And if they do, what about the local residents? For example, if 10% of the commuter population of 100,000 working inCanaryWharfdecide they want to register with a local GP, this will disrupt services for the current local population of 30,000 who are served by 4 GP practices.  They simply do not have the capacity to grow by 30%. And so on.

 ‘Choice’ has consequences, some intended, some not intended. There is no evidence that Andrew Lansley has thought this through; there is evidence that he has not thought this through: see my attempted email exchange with him from March 2010 http://bit.ly/f4iTA1

 See the Royal College of GPs’ response to the New Labour’s so-called consultation on this issue http://bit.ly/l3FrUA

 For a brief overview of the problem http://bit.ly/lo3hWq

For some examples of why this will undermine patient care http://bit.ly/l6fp0v & http://bit.ly/jhqdnw

I am aware that there is a convention that MPs only deal with issues raised by their own constituents, and their expenses.

 I am not writing to you as a constituent, but as a lobbyist. I am not paid by an American private healthcare multinational; I am lobbying as a citizen who happens to be a GP. Why am I doing this, at my expense in terms of time and petty costs? Because I valueUKprimary care and I do not wish to see you politicians flush it down the toilet bowl.

 To the politicians of integrity, I wish you well.

 George

 


My email correspondence with The King’s Fund on practice boundaries, so far

05/06/2011

From: Farrelly George
Sent: 14 May 2011 12:38
To: enquiry@kingsfund.org.uk
Subject: King’s Fund position on GP Practice Boundaries?

 Dear King’s Fund,

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.’

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.

I have included this email on my blog, see  http://bit.ly/loE7uN

Best wishes,

George

 The Tredegar Practice


From: Beccy Ashton [King’s Fund]
Sent: 26 May 2011 17:03
To: George Farrelly
Subject: GP boundary inquiry – final response

Dear Dr Farrelly,

Thank you for your emails which have been passed to me for a response and please accept my apologies for the delay in responding.

As you mention, it was our previous Chief Executive who made the statement to which you referred. Our recent inquiry into the quality of general practice did not look in detail at this issue but I have consulted with colleagues about our current position. We are in favour of the right of patients to choose a GP practice, enshrined in the NHS constitution. It is clear that the coalition government is aiming to increase rather than to restrict patient choice in all areas of health care though as our recent report on patient choice notes, there has not been much focus on increasing choice in primary care. The majority of patients will choose easy access to a practice close to home, but for example there may be some patients who need regular non urgent contact with a GP who would find it more convenient to see a GP near their workplace.

Our current contribution to the coalition government’s listening exercise on the bill considers the GP commissioners’ role and stresses that as far as possible GP commissioning boundaries should be aligned to geographical and local authority boundaries in order to address population health issues including tackling health inequalities, promoting public health and serving the needs of hard-to-reach groups. However, individual practices may not necessarily require a geographical footprint.

In short, we are not in principle against the idea of allowing patients to register with GPs other than in their local area though clearly there are issues that would need to be worked through to ensure the benefits of local registration are not lost.

Regards

Beccy Ashton

Adviser to the Chief Executive, The King’s Fund


From: Farrelly George
Sent: 3/6/11; 09:29
To: Beccy Ashton, King’s Fund
Subject: King’s Fund position on GP Practice Boundaries?; further clarification

Dear Beccy Ashton,

Thank you for your reply to my email on the GP boundary issue. In my email I asked 2 questions: 1. what is the King’s Fund position on the issue of GP practice boundaries, should they be abolished (an anachronism, to be swept away, your previous CEO said)?; 2. Would abolishing them improve the health system in England? If yes, then explain how.

You have answered my first question, though in quite an abstract way. First you say you ‘are in favour of the right of patients to choose a GP practice, enshrined in the NHS constitution’. You then say that the majority of patients will choose easy access to a practice close to home, ‘but for example there may be some patients who need regular non urgent contact with a GP who would find it more convenient to see a GP near their workplace’. The next paragraph is a bit tangential. You then close by saying, ‘In short, we are not in principle against the idea of allowing patients to register with GPs other than in their local area though clearly there are issues that would need to be worked through to ensure the benefits of local registration are not lost.’

You have not answered my second question, which is in essence this: what effect will abolishing GP practice boundaries have on the system? The King’s Fund says its prime aim is ‘to seek to understand how the health system in England can be improved’. This, I agree, is a very important aim, and I am glad that there are people trying to do that. It’s just that in this case I think you (and the Department of Health, and Andy Burnham, and Andrew Lansley, and the three major political parties, so you are in good company) have got yourselves into a muddle. I say this because our practice has in essence been carrying out a de facto pilot on this issue for the past 20 years: what happens to the health system of one GP practice if patients live at a distance from the practice? And we have found it if fraught with numerous problems, leading to poor care for the patient (in some cases with serious consequences), and imposing significant additional demands on limited practice resources. Sure, there are some organised individuals who can pull it off (until they get sick), but as a whole, systemically, it is very problematic.

The difficulty seems to be that you do not actually model your idea (nor does the DoH, nor the ministers). Normally, of course you would. This is presumably what think tanks do: think of all the issues, how the thing will work overall, and so on. In this area of ‘choice’, modelling has been forgotten. It’s as though it is the National Choice Service and not the National Health Service.

Let me give a concrete example: with respect to obstetric care, St Thomas’ Hospital have had a good reputation for many years. We have middle class patients who have done their homework and ask to be referred to St Thomas’ for their antenatal care. Now the response has been that St Thomas’ is unable to accept the referral because they have exceeded their capacity and are only able to accept referrals from within their catchment area. Now this seems to me to be a perfectly sensible stance on the part of this unit. Were they to exceed their capacity, the quality of their service would deteriorate and and risks would increase. So choice in this case is constrained. Now other secondary care units do not have this option to refuse to accept a referral: if a referral arrives, they have to find a way somehow to see the patient, and within a certain time frame. If their capacity is exceeded they have to find a way of increasing their capacity (by hiring locums commonly), and the quality of the service declines (we see this all the time).

In the case of primary care and practice boundaries, the levels of complexity are far greater, the ‘system’ is more complex, the knock on effects more numerous. What Andrew Lansley (and before him Andy Burnham) is proposing is not to find a way for the banker to register with a practice near his place of work (and in this case I can see an argument for finding some solution), but for people to be able to register with a practice ‘anywhere in England’. We have people who would ‘choose’ to remain registered with us though they live on the other side of London and their place of work is nowhere near us.

For concrete, everyday examples of the undesirable consequences of patients living at a distance from the practice, see this.

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Now another area that requires modelling is this: I decide to register with a practice 5 miles away (or 20 miles or 100 miles) because I have heard that Dr Smith is a great GP. The difficulty is that Dr Smith is currently working full time, he has no more capacity. Sure, his practice can expand a bit, get some additional GPs in, but you will not be seeing Dr Smith. Or if you do see Dr Smith, it will be at the expense of some other patient who cannot get in to see Dr Smith. So the whole thing is really a mirage.

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So I repeat my question to the King’s Fund: will abolishing GP boundaries in England improve the health system? If yes, please show how; and show also that you understand how the system works as a whole, and how you are going to deal with the unintended consequences.

Now I don’t really expect you or your colleagues to address this, because you are busy and this is unfunded work. And also because it is a hellish question to answer if you try to do it within the constraints of the real, concrete world.

It is puzzling how presumably clever people can be so myopic about this issue. I mentioned this to an experienced GP colleague from Hackney recently. She said, ‘They’re not stupid. What they are aiming for is opening things up for HMO’s.’

I really hope that the King’s Fund thinks honestly about this issue and really does get to grips with finding ways of improving the overall quality of the system in England.

Good luck,

George

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[if there is further correspondence, it will be added]


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.

 


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.


Are the politicians and health planners very stupid or clever in a devious and corrupt way?

13/05/2011

 

For about two years I have been waking most mornings about an hour earlier than I need to with the thought, ‘How can they be so stupid?’ ‘They’ being the Wankers at the Top (WATTs) at the Department of Health (always anonymous) and their political masters. My particular reason for thinking this thought (2 years ago) was that we were being expected to implement a policy that meant self-destruction for us as a GP practice and the undermining of the quality of the service we provide, all in the name of patient ‘choice’. We solved our particular problem by simply refusing to implement this policy any further, quite openly, pointing out to the PCT the inherent flaw in the design of the policy. Then the focus of my concern became a far worse policy which takes the first policy and magnifies it 100 times: the policy of allowing people to register with the GP practice of their choice anywhere in England. Now perhaps the lay person can be forgiven for thinking this sounds like a good idea: choice has got to be better than limited choice. But for anyone who has worked as a GP for long would see that this was quite unworkable and quite mad. Hence my waking in the morning: ‘How can they be so stupid?’

In an attempt to resist this madness I started this blog, and have been laboriously emailing MPs, journalists, think tanks and anyone else I can think of to alert them to the stupidity of this idea. Everyone else has been caught up with other aspects of the Andrew Lansley’s health ‘reforms’, I have been (unhappily) focused on this one issue because it is the one that presents itself to me on almost a daily basis in everyday work.

Sunday 8 May I woke at about 5:45am; as per usual the thought appeared: ‘How can they be so stupid?’ Sometimes I am able to switch this thought off by concentrating on my breath and thinking of the sea, and I get back to sleep. Sunday morning, however, a plausible explanation came to me as to what the WATTs are up to, what the ‘direction of travel’ is in their minds. And I knew I was not going to get back. So I got up and wrote this post.

*

A few weeks ago I learned about an about to be published book called The Plot Against the NHS. I read the transcript of a lecture by one of the authors which introduced the book.

I ordered the book. One week ago, while on holiday, I finished reading the book. Chilling stuff, and every citizen (and even politicians) ought to read a copy, book clubs should be formed to discuss it. But the authors did not mention this issue of registering with the GP of your choice: how did this particular policy fit into The Plot? I am trying to contact the authors to ask them.

Yesterday I spent some time at the library looking at material related to this blog: I was writing a detailed analysis of an email which the Department of Health had sent me in response to my email to the Health Ministers about 5 months ago. I re-read portions of the Department of Health’s response to the so-called consultation Choose Your GP Practice. My mind began to turn to jelly. I stopped for lunch. I went back to library, packed up my stuff, and went home. We were having people for supper. I spent the remaining time typing some excerpts from The Plot Against the NHS (to include on this blog). Then I stopped.

The human brain/mind is a mysterious and wonderful thing. One example is the way it works on stuff overnight: I go to bed feeling a bit confused or jumbled about something, and often wake the next morning with clarity and a sense of perspective. So overnight my brain/mind worked on the stuff I had looked the day before and presented me with a provisional answer this morning to the question: ‘How can they be so stupid?’

The answer is this: if they were trying to improve general practice as we know it, as it functions when it is working well, then they are quite stupid. But if they have in mind quite a different model, but one they cannot be open about because then the majority of the population would pillory them, then you would have to say they are clever enough, much like the brains behind the banking crisis (the Credit Default Swaps, CDOs, subprime mortgages) and government lobbying that made it all possible were ‘clever’. Then it makes quite a lot of sense, even if it is chilling.

So in a nutshell what my mind presented me on Sunday morning was this: taking into account the thesis presented in The Plot Against the NHS (in essence the privatisation of health care provision in England, essentially on the United States model, carried out by a number of people at the Department of Health, health think tanks, and government–all covertly over the past 10 years or so), the reason the abolishment of practice boundaries is necessary is that it then opens up primary care to large multinationals to bid for and win contracts to provide general practice services the same way that McDonalds provides hamburgers. Let me explain: let us say that Virgin want to provide general practice services. At present they have to bid for individual practices when they become vacant. In addition, these practices serve a local community, within a specified limited boundary (there are perfectly good reasons for this, practice boundaries serve a real purpose, they are not ‘anachronistic’ or outmoded or old fashioned as the Government and Department of Health say). But this is quite limiting if you are thinking of a quite different model. The model might be this: ‘Virgin Health’, a ‘willing provider’, sets up a number of primary care centres around the country (much like Virgin Active has their ‘Health Clubs’, aka gyms), at locations they feel would best suit their business model. Because you are not constrained by practice areas, anyone living inEngland can join any ‘Virgin Health Centre’ inEngland. Indeed, the ‘Virgin Health’ model might mean they have an integrated IT system so your medical record is accessible to any ‘Virgin Health’ healthcare professional at any centre inEngland. So if you are in Swindon on business, just drop into theSwindon ‘Virgin Health Club’ at lunchtime and get your blood pressure checked, and why not step into the adjoining gym while you are at it?

This model would be quite attractive to the mobile youngish person, and might provide a reasonable service for some self-limiting conditions, but it would not do what good quality British general practice does. It would not look after people who have significant health problems, and it would not look after people when they actually get sick and cannot travel to the Health Club for assessment. Not only would it not do what quality British general practice does, it would also be far more expensive. But it would of course make a lot of money for some entrepreneurs.

This, I fear, might be, the ‘direction of travel’.


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)