The plot thickens



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.

The Plot Against the NHS–some excerpts



[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)

If you are a politician…


I appeal to politicians of whatever political party to look into the fine print of the ‘Choose Your GP Practice Anywhere in England’ policy. I know that this sounds like a good idea. Of course, who would refuse the opportunity of choosing whatever GP practice they wished in the whole of England? That can’t be a bad thing! Oh, yes it can…

For the difficulties created by the registration policy enshrined in current GP Contract 2004, click here. This will prime you to consider more clearly the implications of abolishing practice boundaries, and the problems of capacity.

For a brief outline of the problems inherent with Choosing Your GP Practice anywhere in England, click here.

For my email exchange with an MP, click here.

For my email exchange with ‘Andrew Lansley’, click here.

(Please feel free to comment, protest, challenge….)

Reform as sabotage



When I went to a meeting at the PCT in November 2009 to voice my complaint about the patient registration policy, I said that if the KGB had infiltrated the Department of Health and Parliament with the intent of undermining British general practice, this is the sort of policy they would design and implement.

A succession of New Labour health ministers introduced policies which eroded and undermined quality in general practice and called them ‘reforms’. To me, a ‘reform’ is a change you introduce which makes something better. Some (not all) of New Labour’s ‘reforms’, in primary care and in secondary care, made things worse. Can we therefore, please, not call them ‘reforms’?

The following is the first sentence in the current Wikipedia entry for ‘sabotage’:

Sabotage is a deliberate action aimed at weakening another entity through subversion, obstruction, disruption, or destruction. In a workplace setting, sabotage is the conscious withdrawal of efficiency generally directed at causing some change in workplace conditions. One who engages in sabotage is a saboteur.

Andrew Lansley’s plans for primary care (and here I am thinking mainly of the plan for people to register with the GP practice of their choice anywhere in England, but it certainly applies to the other ambitions as well) will weaken and undermine the quality and efficiency of primary care. I don’t think he is deliberately setting out to destroy general practice, but were he consciously and deliberately setting out to do so he would not really have to change much. In that sense, he is an unconscious saboteur, and the workers at the Department of Health are unconscious accomplices.

The Illusion of Choice: Your Choice of Consultant-led Team



“Patients will have choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment. We will extend choice in maternity through new maternity networks.”

This is taken from the executive summary of the government White Paper 2010, and is carried over into the Health and Social Care Bill going through Parliament.

It sounds nice, what’s not to like about it? The problem arises when you have to implement this in the actual world.

It is very important to keep in mind a number of inter-related issues when reflecting on this matter: the quality of a service, the capacity of a system providing that service, the resourcing or resources available to the system providing the service, the access to the service, and the safety of the service.

Take the example of the consultant-led team. These teams consist of a consultant (sometime two working together) and their junior staff (registrars, house officers), secretarial support, managerial support. Part of their work will be outpatient treatment (outpatient clinics), some of it inpatient treatment (surgery in the case of surgical specialties), planned elective admissions, but also emergency admissions. They will also spend time handing over, discussing cases, writing clinic letters to GPs, and perhaps teaching medical students. This team has a finite number of professionals. It is important to view this consultant-led team, together with the service they provide, as a system. And it is important to remember that dynamic systems have an ecology. This consultant-led team will have a capacity: that is, they can see so many new patients in the weekly outpatient clinic. If you increase the numbers you want seen in the clinic, then something has to give. The consultations have to speed up, the quality of the consultations will at some stage decline. The team will have a capacity when it comes to looking after inpatients: exceed a certain number of patients, and the quality of the service declines, and there also comes a time when safety is compromised. You might say, well just hire in more staff. That will work to some extent but remember that as the system gets larger it no longer behaves as it did previously, the ecology has changed. This is what happens if access (choice) is unlimited. You gradually slip into a situation which is Kafkaesque, which becomes a Herculean task.

Why is the RCGP so supine?



Last spring the RCGP invited members to write in with their views to the Government’s so-called consultation ‘Your Choice of GP Practice’. The College said they were going to respond to the consultation and wanted to know our views. I sent my thoughts on April 5, a few days after the deadline. As this particular issue is dear to my heart, I awaited the College response. If there was a publication date, I missed it. Over the summer, I searched for it on the College site but could find no mention of it. On December 11, 2010 I emailed the College asking about it. No answer. I emailed again 1 week later and got an acknowledgement, saying they were passing it to the ‘policy team’. Then no answer. On 16/1/11 I emailed again. No answer. On 3/2/11 I emailed again, this time with a longer email, asking why I was having such a hard time getting an answer to a very simple question. I received a response the next day, giving me some links. One link was old and no longer functioning. The other link did not actually give me the document I was seeking but did take me to a page that, with some protracted searching, led me to the document I was seeking. So here, for those interested, is a link to the document.

 It is a good enough document and covers most of the areas I would have hoped and is pretty unequivocal: abolishing practice areas will create problems and undermine quality general practice. Let me quote paragraph 3:

Only a few of our members were positive about the proposals. An overwhelming percentage (approximately 75%) of our members who responded to this consultation were strongly against the proposals to allow people to register with any GP regardless of catchment area, because of their serious concerns about the potential impacts of this change for the health services provided for patients. Those members who recognised some merits in principal to the proposal also raised a number of serious concerns about the potential implications of the proposals. Our members often did not reply to the specific questions posed for patients in the back of the survey document: the questions were seen as ‘leading’ – implying a positive response to the basic proposal from the start, and thus not allowing respondents to express a strong negative opinion. It also in effect stops members of the public from expressing satisfaction with the status quo.

 In my response to the College in April 2010, I wrote:

Please, please produce a rigorous, strongly argued and fulsome response to this madness. Publish some sort of document and send it to every MP, and publish it online so the public can read it. The difficulty is that from the public’s point of view what’s not to like about this idea. It is just when the idea meets reality that the problems become evident.

The College reponse is good enough. By this I mean the document. The College response, in the wider sense of the word, is, in my view, almost non-existent. My suggestion that they send it to every MP and publish it online so the public can read it has certainly not been followed. Quite the contrary: I, a fee-paying member of the RCGP with a special interest in this issue, have struggled to get my hands on this document.

If you check the Home page of the RCGP today you will see all sorts of stuff about courses, conferences, revalidation, and so on. There is nothing about the Health and Social Care Bill. Why is there not a box somewhere on the home page, with links to other pages? If a politician were to try to do her or his job conscientiously and seek information from the RCGP website, they would find….nothing. What does the College think of the proposal to abolish practice areas? Do they have a view? It can’t be an important issue, so why are a few people making such a fuss?

Because the College is failing in this quite basic responsibility, I am laboriously emailing each MP with a link to this document. I am half way through the B’s.

One of the items that gets centre stage on the Home page is an appeal for funds for the new college site in Euston Square. I for one will not be giving anything for this. RCGP, if you are listening, I do not think you are doing your job. You are hibernating. If you put a an eye-catching link on the Home page to some useful stuff for journalists, politicians, DOH, and members of the public to see, then I will make a donation.

Distance from practice: some recent examples


The following are some examples to illustrate why registering with a GP at a distance has its problems. These examples are all within the past 6 weeks.

1. A man in his late twenties consulted one evening. At the end of the consultation, having dealt with 3 separate health issues which he said he ‘had saved up’, it emerged that he had moved to south west London. I said he would have to get a local GP; he was reluctant: left to his choice, he would have opted to remain our patient. I pointed out that in order to see me he had to travel more than an hour each way. If he were unwell, what would he do? He said he worked in King’s Cross (about 30 minutes by underground, if there are no delays). But to see me he would have to travel 30 minutes further away from his home, and then over an hour to get home. Was this going to favour him seeing me when appropriate? He agreed that this probably was not a good idea.

People in this situation ‘save things up’ because they want to get it all done at once. The trouble with this is that it greatly crowds the 10 minutes we have; the quality of the consultation is lowered as it is hurried, we over-run and so the surgery is then running late which affects others.


2. Patient L is in his/her 50’s. L has been a patient of our’s for years. L moved out of our area, about 2 miles away (15-20 mins each way), some years ago. L was removed from the list, but re-registered at a local address. We subsequently found out L was not living there. L was removed from the list last November but continued to come for repeats but did not register with a local GP. L became unwell in December; L had appointments to see us but did not attend because L’s problem meant that L felt unable to leave home. It was not possible to make a diagnosis over the phone; L needed to be seen in person. Had L lived in our area, we would have visited. L attended A+E on two occasions; on the second occasion, L was admitted with a serious condition, and also an underlying cancer.

We provided prescriptions after discharge (though not registered with us), and did our best to get L registered with a local practice.

[6.8.11: This patient has since died.]

This experience has made us more determined to insist our patients get registered with a local GP: for their welfare.


3. Patient Q had surgery and needed daily dressings. Q’s address was near the surgery (less than 1 minute), but Q had moved 2 miles away, into a neighbouring borough (15 minutes each way by car, unless traffic). Our district nurses visit patients within our patch. They are overstretched as it is, and do not have the resources to see patients in neighbouring boroughs. Had Q been at Q’s registered address, Q might have been able to see our practice nurse, or have a district nurse visit. Instead, Q travelled to the hospital A+E to have it changed; quite an inappropriate model for care, and costly.


4. Patient F recently had major surgery. When discharged from hospital, F went to stay with relatives about 2 miles away (travel time to surgery 15-20 mins each way by car). F probably had a wound infection; I diagnosed this over the phone. I would have preferred to have seen F, but cannot afford to go visiting as time does not permit. Not a desirable model of care.


5. The A family, two parents, three children, moved out of the area, 5 miles away in a different borough. Mrs A has chronic diseases with reduced mobility, and hardly gets out. In recent years, most contact had to be on home visits (5 minute walk). Various services were in place for Mrs A; these services are run for borough residents and do not extend to where they live now. Left to their decision, the A family would have opted to stay with us. This would have led to disastrous care, a model of how not to do it. We had to insist they get a local doctor and in the end had to remove them.


6. Patient S is in his/her 50’s and lives alone; S has a chronic neurological condition which reduces S’s mobility. S was rehoused about 2.5 miles away (travel distance for me 15-20 minutes each way by car). At the moment S is able to manage public transport and wants to remain our patient. I sympathise with S’s request; but I explain that if S becomes unwell, the GP needs to be able to get to S’s home easily. ‘That’s ok, doctor, I will call an ambulance,’ S says. I explain this would not be appropriate. I liaise with a practice local to S and he/she should be able to register with them. I assure S that if S moves back to our area, we will re-register S immediately, without delay.


These are all examples from the past 6 weeks. In each case, distance is a very real barrier to care. In some cases, this barrier makes things unsafe. In all cases it leads to inefficiency and corners being cut. At a time when we are being asked to make efficiency savings, this government wants to introduce a policy that, in its very design, will increase inefficiency considerably and in some cases be unsafe.

I have only listed here examples of patients who have moved a relatively short distance outside our practice area. On the face of it, you might think this would not make much difference. In reality, it does make an enormous difference.


Oh, it has occurred to me to mention 2 instances which highlight in a positive vein what goes right when patients live nearby. Both examples are from last week.

Patient T has a serious mental illness. Patient T came to the surgery seeking help (3 minute walk); T was assessed. My colleague spoke with the relevant mental health team and arranged an urgent assessment at home; T returned to the surgery again and saw my colleague; the community team came to the surgery to give my colleague the necessary papers to sign; the patient was admitted to hospital. This could not have happened if the patient lived 2 or 3 miles from the practice.


Patient R is receiving palliative care at home and is in the terminal phases. I visited the home 3 times last Friday (less than 2 minutes walk). Family members came to the surgery at one point to seek help (less than 2 minute walk). This meant that things were put in place to maximise care for the weekend. This could not have happened if the patient lived 2-3 miles from the practice.


Politicians, please take note. Please engage critical faculties. Do you want choice or do you want quality?

On the loss of critical faculties



I think you will find the following a bit shocking.

 Several years ago, I think it was 2002 or so, I attended a quarterly meeting of an IT subcommittee at the PCT. During the coffee break, one of the managers asked me if I was doing any sessions in the local A+E department the following week. They were recruiting local GPs to do sessions for that week, because there was an audit, a national audit, on waiting times in A+E. I said, no, I was too busy. And thought nothing more of it until a few years later.

Perhaps in 2006 or so I was feeling particularly overloaded with demands being made on us and I found myself reflecting on how mad some of the planning was. I thought back to the A+E audit. An audit is an exercise to find out how something is working. You gather data to see how you are doing. The results then help you plan some changes in order improve things so that you can improve whatever it is you are investigating; then you repeat the audit and see if things have improved.

Now the strange thing about this A+E audit was that it wasn’t going to tell the planners how things were. It was going to tell them how things would be if you hired extra doctors to do the job. Now I am assuming that this audit was meant to answer the question, ‘How are we doing?’ and not ‘How would we do if we hired extra doctors and pulled out all the stops?’

 So an audit was performed; extra money was spent; the results purported to show you how the ‘normal’ service performed, but in reality told you how things would work if you hired extra doctors and did the best you could for a week. The shocking thing is this: you think you are checking on how things are, you are given results. You presumably use these results to plan things. So the results are in reality misleading: they make you think you a doing better than you are, and you have spent extra money to get this wrong data.

This is pretty shocking. But what is also shocking is that at the time I thought little of it. I did not say, ‘This is mad.’ I didn’t even think it. Nor did my colleagues, whom I viewed as thoughtul people.

 And I have observed further anomalies over the years which have been a bit mad, and otherwise sensible, thoughtful people not challenging it but just getting their heads down, and getting on with it.

And so I posited an explanation for this: infection with LCFV (Loss of Critical Faculties Virus). What this infection does is dulls your critical faculties so you become slow-witted, accepting of whatever you are presented with, and you just get on with it.

Once you become aware of this terrible virus, things begin to make sense.

On the Kafkaesque



Kafkaesque: you may be familiar with this term. Not everyone is. I sometimes say to a patient who has brought me a particular type of problem, ‘Do you know the meaning of Kafkaesque?’ Many do not. I then explain that it is a situation where a person feels in a nightmarish situation: they are standing in a queue for hours; then are told that they are in the wrong queue, that they need to go to Section 7 and wait for further instructions; they go to Section 7 and wait; nobody comes for them. They ask for guidance and are told they should not be in Section 7, how silly of them to come to Section 7, they need to be in Section 9a; they go to Section 9a and find a sign which says: ‘Section 9a is closed for refurbishment, please go to Section 7 and await further instructions’. And so on; you get the picture. Patients are usually helped by being aware of this term and its meaning: at least someone has described this, recognised this; they are not alone.

Like the patient who has quite severe, enduring depression; he has seen psychiatrists, is on medication, but feels dreadful, hopeless. He feels physically exhausted and spends a lot of time in bed. He feels ashamed of his inability to get going. He goes to the DWP medical examination (with great effort), and is told, in a letter that arrives a week or two later, that based on the examination (one test was to see if he could fold a piece of paper and put it in an envelope) he has been deemed fit for work, and that his benefit (including his housing benefit which is paying his rent) has been stopped. This is a true story, incidentally, and occurred recently. This is Kafkaesque. The patient appealed the decision; then waited several months (benefits cut off); when he went to the Tribunal they apologised and re-instated his benefit. (In a truly Kafkaesque situation, they would have turned down the appeal….)

The writer Borges said this: ‘Kafka’s most striking talent was for inventing intolerable situations.’

Yes, intolerable situations. Our situation with having to register all patients was Kafkaesque.

The policy of registering with whatever GP you would like, anywhere in England, is Kafkaesque.

That nobody is discussing this policy is, in itself, also Kafkaesque. When I asked about this at a GP meeting a few months ago, I was told, ‘Yes, it is a crazy thing but all 3 parties are in favour of it so there’s nothing we can do.’ They are all worrying about how we are going to form Consortia, grapple with a limited budget, and so on.