NHS 111: If they tried, could they make the communication worse?

27/07/2013

We recently received a communication from NHS 111 about a telephone encounter with one of our patients.

I have removed any identifying details, and I suggest you read it. This is supposed to let us, his GPs, know about the conversation.

If this were a parody, we would say it was over the top.

I actually spoke with this patient soon after this NHS 111 conversation. She/he was on a phone list, waiting for me to return her/his call. She/he had rung NHS 111 to ask the significance of a blood result. It would have been wiser just to wait for me to ring to discuss the result.

That this national programme should have planned for such a shockingly opaque format for communications is very very worrying.

Whoever you are, please go back to the drawing board.


Warning to Health Select Committee on a policy damaging to general practice, from a whistleblower

06/05/2013

I wrote to you several months ago to check if you would be the appropriate body to deal with my concerns about a Government health policy. Two of your members kindly responded and said that it did seem appropriate for your committee. So I am now writing to ask you to look into the Government proposal to abolish GP practice boundaries.

Summary:

The Government and Department of Health wish to abolish GP practice boundaries, saying that it will increase patient choice, drive up quality, and remove anachronistic constraints. From my perspective as a GP with 25 years’ experience of trying to provide good quality general practice to a local community, this policy may sound attractive on the surface, but in reality will simply not work and will cause general practice to malfunction; in some cases it will be unsafe. The Government and Department of Health are either remarkably stupid, or they have a hidden agenda and are engaged in an elaborate deception.

*

1. Who am I and why am I campaigning against this policy? I am a GP in Tower Hamlets. I have worked in our practice for 22 years. I was the medical director of the Tower Hamlets out of hours GP co-operative from 1997 to 2004.

I feel very fortunate and privileged to be working as a GP. Good quality UK general practice is a national treasure, something to be nurtured, protected, sustained.

As GPs we serve a local community. Over the years, in our practice, we have had lots of experience of looking after patients who have moved away, even only a few miles away in Tower Hamlets or Hackney. We have found that these patients tend to delay being seen; that it is more difficult and time-consuming to manage their illnesses; sometimes they are too ill to travel to see us, and we are unable to visit them. At times it is unsafe. (Examples provided in links, see below).

So we are firm with patients about registering with a local GP.

When in 2009 politicians began to say that they wished to abolish practice boundaries, I was bewildered.

2. There are two main reasons why this proposal makes no sense: one, because looking after patients at a distance does not work (for many reasons) and is at times unsafe; two, because GPs are all currently working at full capacity. The ‘good’ practices are already ‘full’ and cannot accommodate a significant increase in demand. There is a risk that ‘outliers’ will take the place of local residents, or impact negatively on the services of local residents.

So there is a very serious design fault at the heart of this policy. For the past 2 years I have been blogging, and writing to MPs, to Ministers, to journalists to draw attention to the problems inherent in this policy.

Last Autumn I wrote 6 articles for Pulse on this issue.

These articles are also published on a separate blog.

3. At first I thought the politicians and the policy makers were just uninformed, unaware of just how misguided the policy was. But I now think that the evidence (evidence that is in the public domain) points towards a more disturbing process at work: that there is a hidden agenda behind this policy. My hypothesis is that the real aim here is to de-regulate general practice. At present, because it is geographically defined, it limits the type of business model that can be used to gain access to general practice. By removing the geographical element in primary care, you change significantly the business models and frameworks that can be applied.

But in order to abolish GP practice geographical boundaries, it has been necessary to create a pretext, or a series of pretexts. A narrative has been created and it has these elements: most people are happy with their GP; but some are not, and they should be able to have choice; GP practice boundaries constrain choice, they are old fashioned, anachronistic; there are a number of reasons why patients might want choice: to have a GP close to work, to register with a GP near their child’s school, to remain registered with their trusted GP should they move away; there might be a GP skilled in a disease in a practice outside their area; the only thing that is needed to make it all work is to sort out how visits will be done should the patient need one.

What this narrative leaves out are the two areas mentioned in (2) above: the systemic problems of patients living at a distance from their GP, and the problem of capacity. It also fails to mention the problems inherent in providing visits for people registered at a distance from their practice (see below).

4. Andy Burnham, then Secretary of State for Health, went to The King’s Fund in September 2009; in his speech he announced his Government’s intention to abolish GP boundaries within a year. He said this move would make a ‘good’ NHS ‘great’ (at least this is what the press reported; I have asked the DH to show me the press release for this occasion; thus far they have been unable to produce this). But what he said about this in his speech really amounted to nothing, it was meaningless to anyone who understands how general practice works (and does not work).

5. The (Labour) Government’s ‘consultation’ on the issue of choice of GP practice, launched in March 2010. If you look at this ‘consultation’ with a critical eye it is clear that it steered the readers towards responding in certain ways to the questionnaire. It used the narrative outlined in (3).

When it published the results of the consultation, the DH claimed it showed that the public backed the idea of choosing your GP practice and doing away with practice boundaries. Of course it showed that, it was designed to show that. Had they been honest about the reality of general practice, the respondents would have said: given what you have told us, why are you even proposing this policy?

6. The DH agreed with the GPC to hold a pilot around this policy. The pilot is in progress. The present Government went so far as to say, in their Mid-Term Review, that this pilot was evidence that the Government had improved the NHS. “We have improved the NHS by …..—allowing patients in six trial primary care trusts to register with a GP practice of their choice.” What the report omitted to say was that GPs in two of the six PCT areas opted to boycott the pilot because of concerns of the impact on resources of the local health economy (one of the many problems inherent in this policy). What they also failed to say was that of a possible 345 practices in the pilot areas, only 42 practices had opted into the pilot, and that as of the beginning of the 2013, only 514 patients had registered with a practice under the scheme.

This ‘pilot’ in no true way tests the policy. The Government and DH say that there will be an independent evaluation of the pilot. Given their behaviour so far, my concern is that the ‘evaluation’ will somehow avoid scrutinising the policy, and deliver a favourable verdict. One way would be to focus on the patient experience, which will no doubt be positive.

7. The problem of visiting. People on all sides of the debate have acknowledged that the issue of visits would need to be addressed. But what most people have failed to grasp is the magnitude and breadth of this issue. At present, all patients are visited by their own GPs within working hours (8am to 6pm [or is it 6:30?]), Monday to Friday. And if the call is outside these hours, then there is a local arrangement for how these visits are covered. There have been problems with out of hours provision, with some high profile cases where patients have died due to not being assessed properly.

If this policy is enacted, then every area in England will require a structure to provide care for those who live at a distance from their registered GP. This provision will have to cover not only the out of hours time slots, but will of necessity be 24 hours a day, 7 days a week.

It is also important to understand that when a patient is seen out of hours, the notes from the encounter are sent to the registered GP. Almost always the notes contain a message that says something like this: ‘If not improving, for review by own GP.’ The trouble with the boundary free model is that there will be no local GP to manage the patient while unwell during working hours and at home. The out of hours service does not provide continuity of care, and does not arrange further investigation and referral where this is warranted.

8. I think there is a case for finding a way to make good quality primary care accessible to people who work long hours at some distance from their homes. But the people designing a solution would have to adopt a sound methodology which would include honesty, common sense, and truly taking into account the ecology and practicalities of general practice.

9. I am making what is a serious and unsettling charge. The people involved in promoting this policy (ministers from both Labour and Conservative parties, and policy makers at the Department of Health) are trying to implement a policy which by its very design will cause primary care services to malfunction and cause real harm. These people have not done an honest risk assessment. They have promoted the policy in a very biased and misleading way. The result is that they have misled Parliament, journalists, and the citizens of England. If this policy were a financial product, it would be deemed mis-selling. In some senses, it is fraudulent.

10. I am writing as what some might call a ‘whistleblower’. That a busy GP should have to spend all this time in trying to get this message through to the politicians seems to me absurd. I am writing in the hope that you will listen and scrutinise this policy. But I am aware that there are many reasons why you as a committee might wish avoid this.

I am also writing so at least at a future date, when the inevitable problems surface, that you will not be able to say ‘Nobody warned us.’

 

Yours sincerely,

George Farrelly

 

The Tredegar Practice 35 St Stephens Road London E3 5JD

 

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Backing documentation

(Numbering corresponds to the paragraph numbering above)

2.. Looking after patients at a distance from the practice does not work and it at times dangerous:

Blog posts by me.

3. a. The narrative: the mainstream press has so far largely just reproduced what the Department of Health Mediacentre have told them in the form of press releases. There have been three main press releases, and corresponding articles in various media. Analysis of these articles shows that mainstream journalists for the most part do not understand how general practice works, and that they have uncritically taken the DH formulations and promises as fact, when in fact they often do not make sense.

 See my post.

In time, the mainstream press may well wake up and look into this issue.

b. The problem of capacity:

In our practice we have struggled with this. Because we are popular, people have wanted to register with us. This has driven us to a list size beyond our capacity which has a negative impact on the quality of the service we provide for our patients, and we have a workload which is unsustainable. The only way we have had to cope with this is to shrink our practice area further a few months ago. So there is no way we could cope with an influx of patients from Tower Hamlets (let alone anywhere in England as Andy Burnham promised), we are drowning as it is.

I came across an example which illustrates this problem recently. There is a practice in Kentish Town with a long established reputation; just the sort of practice that people for several miles around might want to join (if I did not know better, I would consider joining as they are less than 2 miles from where I live). If you go to their practice website you will see the issues they are wrestling with as raised by their patient representation group.

They are having trouble providing access to their currently registered patients, all of whom reside within their practice boundary.

Another example which illustrates this in a farcical way. The DH chose City and Hackney as one of their pilot sites. The City is served by one practice, which has a list size of under 10,000. As it happens, the City of London Corporation and NHS Northeast London had commissioned a study into the practicalities of providing primary care services to the commuter population of the City. The conclusion was that something like 120,000 of the 360,000 commuters were likely to want to register with a GP practice in the City, which would require 50 more GPs, and additional practice nurses and infrastructure. So there was really no way that the sole City practice was going to be able to cater to commuters interested in taking part in the pilot.

See my article.

4. On Burnham visit to King’s Fund, see my post.

5. On Government ‘consultation’, see my post.

6. On the Choice of GP pilot, see my post.

 

 

 


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.

 

 

 


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


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.


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.’


9. How can they be so stupid? Being duped…

05/06/2012

If there is a deception being carried out, then there have to be people being deceived, being duped.

If a politician promises something that he or she knows cannot be delivered, and a citizen believes this, then the citizen has been duped.

If a politician promises something thinking they can deliver it, and a citizen believes this, has the citizen been duped?

In the case of the GP boundary issue, I think it is likely there are some politicians who think it is perfectly practical (in which case they are stupid, and not participating themselves in a deception) and are unaware of the unintended consequences; if they promise their constituent to deliver this is the citizen being duped?

A concrete case: on 30 December 2011 (is there a significance in such a date) the Department of Health launched the ‘Choose Your GP’ pilot. Almost immediately a number of articles appeared in the online press (Telegraph, Express, Oxford Times, and others). These ‘articles’ were essentially all the same, they all repeated what the DOH ‘Media Centre’ told them. They all more or less lifted the text from the DOH webpage. The articles did not say ‘All this content is from the Department of Health as they are giving it out. I cannot guarantee the veracity or reasonableness of the content.’ Nor did any of the articles analyse what was being offered, ‘promised’. They just presented it. A citizen reading the article could be excused for thinking the content, the promises, were reasonable and achievable.

So in this case, the journalist is being duped, and in turn, unwittingly, is duping the public.

(I checked this with one of the journalists, and offered some additional information which critiqued the content of the DOH webpage; the journalist said that he/she had had to rely wholly on the DOH content; and had he/she been aware of what I had told him/her, he/she would have written a different story. There may be more on this in the future).

DOH ‘Media Centre’ Launch

Two examples (there are at least 5 others):

Oxford Times ‘article’

Express ‘article’


6. How can they be so stupid? Stupidity-to different degrees, at times grotesque

05/06/2012

The Oxford Dictionary of English has next to nothing for stupidity. For ‘stupid’: lacking intelligence or common sense; dazed and unable to think clearly: apprehension was numbing her brain and making her stupid

lacking intelligence: yes, this is relevant

lacking common sense: yes, definitely

dazed: they should be

unable to think clearly: yes, many examples of this

 


5. How can they be so stupid? Ignorance, wilful and unwilful

05/06/2012

With the issue of GP practice boundaries, there is in general a very limited  understanding about general practice actually works, about how good quality general practice works. Even our hospital doctor colleagues often do not understand how it works.

Good quality British general practice is a very complex technology which serves local communities in geographical areas. You need to have an understanding of this and how it works. Otherwise, you are ‘ignorant’.

A GP colleague of mine has been to a number of events organised by the Department of Health in recent months. She has been struck by how ignorant the people from the Department of Health are about how general practice works, how general practitioners work, how good quality British general practice works.

‘Wilful ignorance’: don’t confuse me with the facts.


1. This really has to stop

05/06/2012

For over 2 years now most mornings I wake up earlier than I need to and my mind fixes on the issue of GP practice boundaries and, in one form or another, I think ‘How can they be so stupid?’ ‘They’ being the politicians, the Department of Health, journalists, think tanks, patient representatives. I don’t on the whole include members of the public, simple citizens in this. Because they are being fed stuff by the politicians, journalists, think tanks, and who could blame them for thinking it is reliable stuff?

Why am I doing this? Why am I writing this early on a Bank Holiday morning when I could be in bed sleeping, reading a book, gardening, or going to work to try to catch up on the massive backlog (which I will do later on as it happens)?

I came to medicine late, I was about 6 years older than my peers at medical school. I made a positive choice to become a general practitioner, because I welcomed the chance of working in a community, with families, over time. My wife and I started in our practice in Tower Hamlets 21 years ago. We, and our colleagues in the practice, try to provide a good service to our patients, and to create a healthy environment in which to work.

We, like all GPs, have a geographical practice boundary. To register with us you need to live within that geographical area, if you move outside that area you have to find another GP in whose practice area you live. It seems harsh, but there are a number of practical reasons for it. What I tell patients when they move is simply this: it is important that you be able to get to the surgery easily or for us to get to you easily if you are sick. (There are a raft of reasons why this, from a practical point of view, is necessary). Patients nearly always see why this is necessary.

We have quite a lot of experience of looking after patients who have moved out of the area and not told us. They have continued to use us as their GPs but it simply does not work properly, for a variety of reasons (in some cases it is unsafe, and can be fatal). So we are pretty firm with people on this score, but give them adequate time to find a new GP.

There is another aspect to this question. We work in Bow. We have a limit to how many people we can look after; if we exceed this capacity, the quality of the service we offer declines and the dynamics within the organisation become unhealthy. So we have an upper limit of the number of patients we will register. So if a patient moves away from Bow (to say Brixton), that patient’s place is then taken by another resident of Bow who wants to join us.

So when, in September 2009, I heard that Andy Burnham wanted to abolish GP practice boundaries and give people ‘real choice’, I thought: ‘How can that man be so stupid?’

Then there was the ‘Consultation’ in March 2010; the General Election which brought us the Coalition Government and Andrew Lansley; Andrew Lansley’s vision to bring everyone more choice, and his commitment to abolishing practice boundaries.

But the trouble for me was that I actually worked in the field that they were talking about, and I had daily reminders about the fact that general practice is a community based technology tied to geography, and that to severe its tie to geography simply did not make sense. It simply did not add up. There was a cognitive disconnect.

And so I woke up early asking the question, ‘How can they be so stupid?’ And having followed this issue over the past 2 years, I am still waking with this question, in fact it is seeming to me to be more and more stupid.

But it really has to stop.