Why GPs have practice boundaries

11/05/2013

[The following is an article published in BMA News, January 14, 2012, by Flora Tristan. It is no longer accessible online, so I am making it available here.]

We’ve been expecting this.

It’s Monday morning, I’m on call, and we are — as usual — a touch light on doctors. One colleague is consulting in addition to me, and a locum is booked to come in at 11am, though it’s not clear yet whether he will do any visits or scripts. At 8.50am a call for an immediate visit comes through, and it is all I can do not to say ‘I told you so’.

I establish that Alfie’s dyspnoea is not such as to justify a blue-light ambulance but is too serious to wait till later in the morning. My colleague assures me that she can deal with her surgery, probably the bulk of my surgery, phone calls, enquiries, immediate scripts, immediate collapses in the waiting room and immediate everything else, and I head out into the freezing sleet.

It takes me 40 minutes to get to Alfie. Partly, this is because I have to negotiate a road junction that is so notorious that it has frequently been a topic for debate in Parliament. But the main reason is because Alfie lives absolutely miles outside the practice area, and has done so for years. I pass five surgeries on my way, including the excellent practice opposite Alfie’s house.

When I get there, Alfie is in extremis with an exacerbation of COPD, and his daughter, Jane, who has learning difficulties and asthma, is crying.

‘He didn’t want to call you — said it was too far for you to come, doctor,’ she says. I wait with Alfie, and encourage him to use his oxygen while the ambulance comes. Then I get on to social services to arrange Jane’s care for the next few days. By the time I get back to the practice there are two complaints pending, 14 people are still to be seen, and my normally serene colleague is close to tears.

This morning was always going to happen. This is why I have been pushing and pushing in meetings for us to encourage Alfie and Jane to register locally. Not only has a single visit seriously impaired the care we can offer to other patients this morning, never mind causing substantial stress; Alfie’s care has also been affected by the distance he lives from the surgery, since he has been reluctant to call when he should have done so.

Today I am really not interested in the sentimental view of one colleague that Alfie should stay on our list as he has been with us for so long and he is frail. That is exactly why he would be better off with the practice across the road from his home. Nor am I inclined to ‘be flexible’, as the health authority suggests; it is only worried about the local press. We have practice boundaries for a reason, and this morning is it.

Flora Tristan is an inner-city GP


Letter from a mum with a reason to stop privatisation NHS

06/03/2013

I received this email from Linda via 38 Degrees; it is self-explanatory. Please sign the petition if you have not already done so.

 

Dear George,

My name is Linda. I’m a long-standing 38 Degrees member, and I’m sending this email because I know first hand why it matters so much to stop the privatisation of our NHS.

On Friday afternoon, I will deliver a copy of the petition against NHS privatisation – which you and I have both signed – to the Health Minister.

When I hand the petition over, I will tell the Health Minister about what happened to my baby. He died when he was just seven weeks old whilst receiving care from my GP out-of-hours service – which had been recently privatised.

Can you help me have as many names as possible to hand in on Friday afternoon, by forwarding this email to as many of your friends as possible asking them to sign it too?

They can sign by simply clicking this link and adding their names:
https://secure.38degrees.org.uk/nhs-section75

Last week was a hard one for me. It was the inquest into the death of my baby son, Axel. He died last November from pneumonia. His illness went untreated despite repeated calls and visits over the course of five days to my NHS out-of-hours doctors’ service, which had been recently privatised.

I feel the inquest left many of the biggest questions unanswered – like what role NHS privatisation may have played in the mistakes which led to the death of my baby boy.

After hearing evidence of how that private health contractor had acted, I feel determined to do all I can to stop further privatisation of our NHS. That’s why I’ve decided to get more involved with 38 Degrees, and why I’m going to see the Health Minister this Friday. I’d really appreciate it you could help me get more names on the petition before I meet him.

Please, pass this email on, and ask your friends to sign the petition for this important campaign:
https://secure.38degrees.org.uk/nhs-section75

We had a bit of a breakthrough with this campaign yesterday. The government announced that because of all the pressure they would withdraw and rewrite their NHS privatisation regulations. The petition which I’d signed, along with 240,000 other 38 Degrees members, was mentioned in Parliament. That shows we can make a difference.

But I remember, as I’m sure that you will, that when the government promises to rewrite a plan, that doesn’t necessarily mean that the new version will be any better than the old one. We need to make sure they genuinely drop any attempt to force GPs to open up services to privatisation.

I would love to have as many signatures as possible by Friday afternoon when I visit the Health Minister. Please pass this message on to anyone you think might be interested: https://secure.38degrees.org.uk/nhs-section75

Thank you.

Linda

PS: You can read more about what happened to my baby in this piece in the Guardian: http://www.guardian.co.uk/society/2013/mar/02/nhs-commercialisation-bereaved-mother-fight But please sign the petition first: https://secure.38degrees.org.uk/nhs-section75

PPS: This email has been sent from Linda Peanberg King using the 38 Degrees system. Your email has not been shared with anyone else.

PPPS: In case you missed it, below is the 38 Degrees email we sent out last week at the start of this campaign:

A new fight over NHS privatisation has just begun. Jeremy Hunt is trying to use new powers, hidden within last year’s controversial NHS laws, to force local GPs to privatise more health services. [1] This is one of the things we were afraid might happen – and now our worst fears are being confirmed. We need to do all we can to stop it.

Jeremy Hunt’s new privatisation plot is contained within “NHS competition regulations”. [2] Usually these kinds of rules get quickly rubber-stamped by Parliament. This time, we need to get MPs and Lords to stand up to Hunt and block his plans. [3]

It’s a long shot, but we have a chance of stopping these changes because Hunt is breaking promises made to MPs when NHS laws were voted through last year. [4] If we generate a huge, public outcry to put pressure on the politicians who clung on to those promises last time the government attacked our NHS, we can convince them to stop these new laws.

Sign the petition against Jeremy Hunt’s new NHS privatisation plan here – we’ve got just a couple of days before we’ll need to deliver it:
https://secure.38degrees.org.uk/nhs-section75

Hunt’s new regulations (Statutory Instrument 257 under Section 75 of the Health & Social Care Act 2012) are like a catalogue of our worst fears. [5] GPs would have to open up every part of local health services to private companies, whether or not it’s what they or local people want. It would speed up the break up of the NHS, giving profit-hungry companies new rights to muscle in.

Last year, the government promised it wouldn’t go as far as forcing privatisation on local health services. Lots of MPs and Lords said these promises convinced them to vote for the NHS law. Now, we need to go back to these same MPs and Lords, and tell them to find some backbone. If they really voted for the law because of those promises, now they’ve got no excuse not to put a stop to Hunt’s latest privatising move.

Let’s build a petition to hand in to each of the MPs and Lords who believed the government’s promises on privatisation:
https://secure.38degrees.org.uk/nhs-section75

All over the country, 38 Degrees members have been working together to convince their local NHS decision makers to do the right thing and limit privatisation in their area. Now, government is trying to take that power away from local doctors and the patients they serve.

This is going to be tough. It could be the start of the second round of the fight to protect everything that’s precious about the NHS. But it’s the right thing to do, because we know that when private companies move in, all too often it doesn’t end well for patients.

Sign the petition now:
https://secure.38degrees.org.uk/nhs-section75


Calling on doctors to sign letter to The Times; deadline Monday morning 5 Sept

03/09/2011

A Tweet this morning mentioned a letter to the Times for doctors to sign; I tracked it down, and reproduce it below. If you sign up, make sure you give your title, name, place of work and phone number (this is to ensure people are for real).

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Would anyone be willing to sign the following letter to the Times?

Please feel free to forward to medical colleagues, including people outside Liverpool, or to circulate by any other means you can think of.

Unfortunately the timescale is again very pressing – I will need to submit the letter on Monday morning for publication on Tuesday (when the bill returns to the commons). Please ask people to reply to me at <

mailto:Jonathan.folb@nhs.net>, and to include their job title and location.

Thanks, jon

Dear Sir,

On 20 July, the national Council of the British Medical Association (BMA) agreed to start a public campaign calling for the complete withdrawal of the Health and Social Care Bill. This was in recognition of the medical profession’s overwhelming rejection of the Bill, and a failure of the government to address adequately concerns about the further privatisation of the National Health Service. It was also agreed that the government is misleading the public by repeatedly stating that there will be no privatisation of the NHS.

As doctors working in England, we agree that this legislation will cause irreparable harm to the health service if passed in any form. The misguided focus on competition, and on service provision by Any Qualified Provider, will result in a fragmented and unequal service, with a loss of public accountability, and a damaging focus instead on services which are financially profitable.

Although the Bill has been presented both to the public and healthcare professionals as a “done deal”, it lacks an electoral mandate. It is being rushed through at great cost, despite the serious concerns of healthcare experts and professional bodies, and with scant regard for evidence or any provision for piloting.

We applaud and support the position adopted by the BMA Council, and call on the government to withdraw the Bill.


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.

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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’.


If you are a journalist…

27/02/2011

It must be said that these two related issues are not sexy. There are no naked breasts involved. But in a real sense they are scandalous.

The first problem, that of the current registration policy, involves a design feature in the 2004 GP Contract which, in our case, leads inexorably, predicably, to a decline in quality (and safety) of care, eventually to self destruction.

For a brief outline…

The second problem is the Government proposal to abolish GP practice boundaries. (In fact, all parties apparently favour this). This sounds like a good idea, who wouldn’t like to have the option of choosing whatever practice they would like in the whole of England, regardless of where they live? But would it work?

For a brief outline…

Also:

My email exchange with ‘Andrew Lansley’

My email exchange with The King’s Fund

My email to the Patients’ Association