Lansley promise 2011: “NHS patients will be able to pick consultant”. September 2015: Where are we now?

26/09/2015

An article appeared in The Independent in October 2011 which reported that Andrew Lansley was going to make it possible to pick the hospital consultant of your choice. It seemed to me to be a moronic idea at the time and you can see why in a post I wrote at the time. (In fact, I discover that I wrote an earlier post pointing out the absurdity of promises made in the White Paper which then led to the Health and Social Care Act; it is worth looking at both these posts in view of where we are now.)

So where are we now? Let me tell you how it is for me, referring patients to hospitals in London. Yesterday I spent about an hour trying to arrange an appointment for two patients failed by the system, entirely predictably. One concerns Patient X who has chronic back pain who has had an MRI scan of her/his lumbar spine, and the report recommended referral for possible spinal surgery (I asked for advice from our local spinal orthopaedic surgeon, he advised referral); the other concerns a baby under 1, referred to a London centre of excellence.

I referred Patient X six weeks ago through the Choose and Book system (recently rebranded as the NHS e-Referral Service). What choice did Patient X have? Well, there are two avenues for this sort of situation: a spinal orthopaedic surgeon, and a spinal neurosurgeon. I tried the orthopaedic surgeon first. The wait for our local spinal orthopaedic surgeon at the Royal London Hospital was 185 days (that is, over 6 months); there were not many other options, with similar waits. So I tried spinal neurosurgery. Here the choice was even more reduced, but there was one option: an appointment in 41 days at the National Hospital for Neurology and Neurosurgery. I clicked this option, printed the form and gave it to Patient X to book the appointment online.

When Patient X tried to book the appointment, there were no appointments; Patient X was told that she/he would be contacted by the hospital within 2 weeks regarding an appointment. This did not happen. So Patient X rang the NHS e-Referral Service; they could not help her/him, she/he needed to ring the hospital. Patient X rang the hospital and was told the they would contact her GP to confirm that a referral was necessary (a strange step as I had referred Patient X in the first place). In any event, I did not hear from the hospital.

So yesterday I rang the NHS e-Referral Service. They could not help me, it was out of their hands. I did point out a generalised problem, which was illustrated by the individual case of Patient X. In my experience, whenever the patient finds there are no listed appointments and are told they will hear within two weeks, it usually means an appointment will not be forthcoming; & when the patient pursues it with the hospital they will eventually be told there are no appointments and to go back to their GP (!). And then what I do is start again: I raise another referral through the e-Referral Service but warn the patient not to choose an option that does not give them an actual appointment. So yesterday I spoke with a manager at the NHS e-Referral Service and I told her about this problem. Initially she was evasive and defensive, but then softened and agreed that in these cases the system did not work. I suggested she take this back to her organisation and ask that they at least be honest about this issue and warn patients booking with hospitals who do not have appointments listed.

I then rang the Hospital for Neurology and Neurosurgery. I explained the situation; that the patient had been told I would be contacted; that I had not been contacted. On the NHS e-Referrals system, Patient X’s referral is currently categorised as ‘Deferred to Provider’. The staff member at the Hospital for Neurology and Neurosurgery said that this meant me, her GP. I said I did not think so; I thought it clearly referred to the hospital to whom I had referred the patient. I was then advised to fax a copy of my referral letter to the staff member and that she/he would pass it on for vetting.

With respect to the baby, exactly the same thing has happened. No appointment. Parents told to go back to their GP. I have made a new referral, and chosen only providers who actually have appointments. (The hospitals without current appointments will be listed as ‘Unknown’ as the date of next appointment).

This situation is not unusual. With respect to my local hospital, the Royal London Hospital, many specialties have long waits or are ‘Unknown’. My impression is the ‘Unknown’ category is actually a way of avoiding these referrals appearing in the statistics; if the hospital were to give an appointment that is more than so many days, then that is a breach of the targets and there is a financial penalty. So if they do not give an appointment, if they tell the patient to go back to their GP, perhaps they avoid this breach. I think it is likely that this is what is happening. I could of course chase this up further and get to the root of the problem, but I am a GP, not an investigative journalist (not many of them around these days). Our CCG sent us Tower Hamlets GPs a letter recently advising us not to refer to certain departments at Barts Health since they are having considerable problems with capacity. This is all very well, but then we refer to alternatives like the Homerton Hospital; and it does not take a genius to realise that these alternative providers also face the reality of capacity and their waits will lengthen and possibly/probably go beyond the target and then breach and be financially penalised.

So there is quite limited ‘Choice’; what Lansley and the DoH promised was moronic from the start, the current situation was entirely predictable. Is it the hospitals’ fault? No, it is an absurd Herculean task. What we need is people to be honest about this, to fight back and point out the absurdities in the demands being placed on NHS services by Morons in Government.

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For a picture of London spinal neurosurgery referral options as of yesterday, Spinal neurosurgery options on 25.9.15.

 


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


NHS Choices Website: my attempt to leave a comment regarding ‘Patient Choice Scheme’

14/04/2013

A few weeks ago, I found the NHS Choices page promoting the ‘Patient Choice Scheme’. I registered and left this comment:

I am a GP in Tower Hamlets, one of the sites chosen for this pilot. What the Department of Health is not telling you is that two of the 6 sites above (Tower Hamlets and City and Hackney) have refused to take part in this pilot in order to protect the local health economy and services to our local population.

The proposed policy to abolish GP practice boundaries is deeply flawed, but the Department will not tell you that.

For more information, see www.gpboundaries.org

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I checked this afternoon, and noticed that my comment (which I thought had been accepted on 31/3/13) was missing. There are in fact no comments to this page. So I have tried again. My Comment on Choices website but somehow feel that it won’t be visible, ever, to anyone else.


Will the real Neal Bacon please stand up?

09/03/2013

I had not heard of this man until yesterday. There has been some Twitter activity about him today, much of it raising questions. I followed some of the links.

There is enough to raise questions about his credibility, and ask for some clarification.

His blog claims he was a ‘nephrologist’, Harvard and Oxford trained. I would like to know what this means. I would like a list of the jobs he has done. Does he have MRCP? How high up the training ladder did he go? According to the GMC site, he is   a registered doctor, fully registered in 1991, but not on the Specialist Register. So is he misrepresenting himself?

I came across this blog entry from 2008. (This is what sent me to the GMC; you can check his registration, just enter name and surname).

And then this helpful page from Dr Rita Pal.

And then, ironically, given his enthusiasm for patients rating their doctors, this page where patients rated him 2.2 out of 5. But God only knows what that means.

 

 

 


12. How can they be so stupid? Brain damage

05/06/2012

While on holiday recently I read a book on the neuroscience of pleasure (David Linden, The Compass of Pleasure). The idea came to me that in some sense the policy to abolish practice boundaries and extend patient choice is actually ‘brain damaged’.

In this sense: the book discusses the way in which various pleasures (sex, certain foods, drugs, behaviours like gambling) activate discrete parts of our brains, which we then experience as pleasurable. The author highlights situations where, under the influence of certain pleasurable experiences (such as falling in love) there is a distortion of our critical faculties, a ‘deactivation of the prefontal cortex’, the judgement, planning, and evaluation centre. Money, cocaine, heroin activate these pleasure centres.

It occurred to me that possibly the thought of choice, the promise of choice, somehow activated the pleasure centres, and led to a deactivation of the prefrontal cortex, a distortion of our critical faculties.

This is perhaps just a metaphor. But it certainly seems to me that certain policies from the DOH appear to be ‘brain damaged’, that is to say that important thinking steps are simply left out.


11. How can they be so stupid? Cognitive Muddle

05/06/2012

At the heart of this issue of patients’ choice of their GP practice there is a significant amount of cognitive confusion and muddle. What I mean is the sentences used are disconnected from reality, there is a disconnect. It is as though if the sentence sounds ok, then just go with it. Don’t actually try to see what it means in real life. There is an ignoring of the paradoxes.

It is as though a potician were to say: ‘I believe wholeheartedly is a strong family life and a lifelong committed marriage to my wife, and also having the choice of which mistress I have on the side at any given time.’

So Andrew Lansley says to the RCGP:’I’m not abolishing practice boundaries…I’m intending to extend patient choice.’

Many do not seem to be aware that there really is no choice, it is illusory. Current GP practices are all working at capacity, there is not significant spare capacity. If the practice area were suddenly to become the whole of England (or just the whole borough), there is no way that the practice could register the patients. This is such a basic reality, such a simple fact, and yet the muddle persists.

Another cognitive muddle is the argument that opening up practice areas will result in competition and improved quality of the poorer practices. But again, this is absurd because of this issue of capacity. Yes, a few patients might move from practice x to y, but it can only be limited. This is not same type of market as hamburgers and mobile phones.


10. How can they be so stupid? Wishful thinking….

05/06/2012

If you are offered something attractive by someone, you naturally hope that it is what you are going to get. You hope it ‘will come true’, that it will not be illusory.

The property bubble and the disastrous crash in 2008 was at least in part built on ‘wishful thinking’. Bernie Madoff’s ponzi scheme went on as long as it did at least in part due to ‘wishful thinking’ on the part of his investors.

If Andrew Lansley is going to offer you choice, why turn him down?

‘I mean choice, at no cost, it can only be a good thing, right? We have the Department of Health’s assurance on this, right? I’ve read the leaflet, what’s not to love about it? Sure, I’ll go with choice, it’s a no brainer.’