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.
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