Two members of Health Select Committee respond to my email on GP practice boundaries

04/10/2012

I emailed members of the Parliamentary Health Select Committee earlier in the week. I have received a reply from two of the members, Sarah Wollaston (herself a GP), and Barbara Keeley. Here are their replies:

Sarah Wollaston:

Dear Dr Farrelly,

This does look like the kind of issue that the HSC could look at but we have many outstanding and potential enquiries and the whole committee vote to decide on the order in which they are examined. I’d be happy to see this added to the list as part of the wider review of GP services and the important issue I’ve already raised of understaffing. I agree this issue of boundaries is very important.

Best wishes,

Sarah

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Barbara Keeley:

Dear Dr Farrelly,

Thank you for this, it is very worrying.

As far as I understand it, the brief of the Health Select Committee is to hold the Department of Health to account:

The Health Committee is appointed by the House of Commons to examine the policy, administration and expenditure, of the Department of Health and its associated bodies.” (quote from Committee’s page on the website)

So the matter you raise would fall within the Committee’s remit.

Best wishes

Barbara Keeley MP


8. How can they be so stupid? Duplicity

05/06/2012

Duplicity:Oxford Dictionary of English: deceitfulness; archaic the state of being double.

Andrew Lansley gave a speech to the Royal College of General Practitioners’ annual conference in October 2011. I did not attend but fortunately the speech is available on video, as are the questions and answers after the speech. So I was able to listen to these. What he had to say about GP boundaries was actually not unreasonable, he seemed to have understood the problem (‘Now I’m clear that whatever we do general practice must always remain rooted in local communities and that clinical commissioning builds on this.’; whatever was done had to work, they had to find ways that worked; ‘I’m not abolishing practice boundaries…’). But I was sceptical: let’s see what happens. A few weeks later the GPC signed a contract for 2012-13 which agreed to a pilot on GP practice boundaries, and for asking practices to create ‘outer practice boundaries’ which retained patients who moved from within the practice boundaries. This was not unreasonable, but I remained sceptical: how independent and probing would the ‘independent evaluation’ of the pilot be?

Then came the launch of the pilot, at the end of December 2011:

It allows patients for the first time to choose whether to register with a practice close to their workplace or home, without worrying about practice boundaries.

Health Secretary Andrew Lansley said:

‘Many patients are happy with their local GP practice, but a significant minority have problems registering with a practice of their choice. This pilot will mean patients taking part can access the high quality care they deserve in a place and at a time that suits them.

‘That’s why I believe patients should have the freedom to choose a GP practice that suits their lives, and not be restricted by geographical boundaries.’

He did not really believe what he said to the GPs in October. He was intelligent enough to know what sort of thing he had to say in order not to be eaten alive, but his intention was, and still is, to plough ahead with the abolition of practice boundaries. And this is how it was reported in the press.

In this sense, he is duplicitous, ‘double’, speaks with ‘a forked tongue’. Not to be trusted.

(For text of what he said to RCGP)


3. If it is so stupid, why are they doing it?

05/06/2012

I have reflected for over 2 years about this. If the proposal to allow patients to register with any GP in England, regardless of where they live, is so stupid, how is it that all three main political parties back the proposal, the Department of Health backs the proposal, journalists do not question the mechanics behind it, and, in the ‘Consultation’ over three quarters of the members of the public who responded allegedly backed the proposal?

I would say there are a variety of reasons, but all in the end come down to a misunderstanding of the situation, of the facts. This misunderstanding is the result of:

Naivety

Ignorance (wilful and unwilful)

Stupidity (to different degrees, reaching at times the grotesque)

Misinformation (wilful and unwilful)

Deception

Duplicity

Being duped

Wishful thinking

Cognitive muddle

Brain damage

Corporate lobbying?

‘The Plot Against the NHS’

Bad Faith (a future post)

(other suggestions welcome)


Tower Hamlets CCG opposes Health and Social Care Bill

28/02/2012

The Tower Hamlets CCG (Clinical Commissioning Group), having conferred with the GP body in Tower Hamlets, have sent the following letter to David Cameron. See text below; see the actual letter here CCG letter opposing Health and Social Care Bill.

Tower Hamlets Clinical Commissioning Group

27 February 2012

The Right Honourable The Prime Minister

10 Downing Street

London

SW1A 2AA

Dear Prime Minister

The Board of NHS Tower Hamlets Clinical Commissioning Group ask you to reflect and to withdraw the Health and Social Care Bill.

Supporting improvements in the quality of patient care is our passion and focus. We support a strong role for clinical involvement in commissioning decisions that lead to better health outcomes for our patients. We do this already in Tower Hamlets.  An Act of Parliament is not needed to make this happen.

Tower Hamlets Primary Care team has a long tradition and reputation for innovation and commitment to partnership working with patients and managers. We make the best of any challenges that come our way. Innovations include real improvements in the health of our patients with chronic illnesses like diabetes, the highest childhood vaccination rates in London, and an exemplary local out of hours service, delivered by our GPs and highly valued by patients.

We work in partnership with the community, hospital, local authority and community organisations, to improve and integrate services for the benefit of our patients. It is against this background that we represent the views of our local GPs in asking you to withdraw the Bill.

You are familiar with the submissions on the long-term implications of the Bill made by our professional representative organisations, the Royal College of General Practitioners and the British Medical Association. We share their concerns.  We add to that our own experience. Clinicians, patients and managers in Tower Hamlets are determined to improve health and well-being, but your rolling restructuring of the NHS compromises our ability to focus on what really counts – improving quality of services for patients, and ensuring value for money during a period of financial restraint.

We care deeply about the patients that we see every day and we believe the improvements we all want to see in the NHS can be achieved without the bureaucracy generated by the Bill.

Your government has interpreted our commitment to our patients as support for the bill. It is not.

Yours

Dr Sam Everington

Chair, NHS Tower Hamlets Clinical Commissioning Group

c.c. Andrew Lansley, Secretary of State for Health


My email to Patients Association about bid to abolish practice boundaries

12/06/2011

 

Dear Vanessa Bourne, Celia Grandison-Markey, and The Patients Association,

I am a GP in Tower Hamlets. I heard the radio piece on GP practice boundaries on the Today Programme last Wednesday morning as I was driving into work. I have a particular concern about this issue.

My wife and I have been GPs in a small practice in Tower Hamlets since 1991. When we were interviewed to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ (patients living outside the practice area). It was then considered poor practice to have patients living at a distance from the practice, and good practice to serve a community of people who lived close enough to the practice to maximise access and integration with other services. We have in fact attempted to serve such a community and are pretty firm with patients who move away (as is common in inner city London practices, there is a fair turnover of patients). We have had quite a lot of experience with patients who continue to use us as their GPs even after they have moved away, and it has only confirmed us in the conviction that is not possible to deliver good quality care to people who live at a distance from the practice. The problems are directly proportional to the distance from the practice. Of course there are individual exceptions, but in general patients do not access us appropriately (they delay seeing us; they save up lots of problems which we cannot deal with in a single appointment), or they expect us to deal with problems over the phone which really require a face-to-face encounter, corners are cut, and sometimes it is actually unsafe. And on and on.

Then there is another problem, and it is one of capacity. We are currently unable to register all patients living within our practice area who choose to register with us. Demand exceeds capacity. If we exceed our capacity, then the quality of the service we offer our patients is compromised and quite quickly things become unsafe. So we have had to take the decision, in breach of the 2004 GP contract, to set a limit on our list size. As people move away, we can register more patients, trying to maintain a list size of 3,520 patients.

Now I sympathise with your wish to meet patients’ needs. There really is a problem for some to get registered with a practice that offers a ‘good enough’ service. But this policy of abolishing practice boundaries will not, as a system, solve the problem. Sure, there may be a few patients who will benefit, but the overall effect will be negative. And this for the two general reasons outlined above: 1. the complexity of providing good quality general practice and how distance impacts negatively (there are a host of other issues such as the problems with commissioning services with a budget that is for a local population, and so on); 2. the problem of capacity. In fact, this second aspect of the proposed policy makes the policy unworkable. What I mean is this: most GPs (if not all) are currently working at full capacity. If more than a handful of extra patients wish to register with a popular practice, it will impact on that practice. All practices will, at some point, reach their capacity. If they exceed that capacity, the service will suffer. If patients outside the practice area displace local residents, this will be at the local residents’ expense.

To give you an example from Tower Hamlets: CanaryWharf has a commuter population of approximately 100,000. The resident population of the Isle of Dogs is about 30,000 and is served mainly by 4 practices. If 10% of the commuters to CanaryWharf ‘choose’ to register locally, it would have a very significant impact on the local GP services.

For the reasons I have sketched above, our practice will be unable to provide services to patients outside our current practice area. We would simply refuse to do it and make it clear why. It would be perverse to look after patients who live outside our area (which we feel is at best inefficient, at worse unsafe), and have fewer places on the list for local residents.

I am afraid the politicians have made promises which they simply cannot keep. Blame them, not the GPs. Many of us are doing a very difficult job as best we can. When we are then landed with policies which make our job even more difficult and which are very poorly thought out, it is very demoralising.

Vanessa Bourne said in her contribution on the Today Programme, ‘Here we have something that has nothing to do with the patient, only to do with their address.’ I would challenge this and say that our practice area allows us to serve a local community with maximal efficiency and efficacy, and this has everything to do with the patient. The reality is that the vast majority of patient-practice transactions that take place are local ones.

So I feel that what is actually needed is attention given to raising the standards of practices in general (where this is needed), so that people do not have to travel to access good general practice. There may in some cases be an argument for some people registering with a practice near their work (but what happens when they become unwell?), but this is not the same as allowing the whole English population to register with the practice of their choice anywhere in England.

I started a protest blog about this issue several months ago, and for a time it felt mine was a lone voice. Most people were taken up with other aspects of the Health Bill (and rightly so). I was encouraged to see that the LMC conference a few days debated this issue and it would appear that the GPC is going to fight this pretty robustly in the coming months.

It is important that you are aware of the complex reasons why practice boundaries exist, and that they are not simply arbitrary lines on a map meant to deny people choice. That is not to say that there not people who experience them, understandably, as a significant frustration.

I almost forgot: I would strongly recommend you get hold of a book called The Plot Against the NHS, by Leys and Player. It is an analysis of the behind the scenes goings on in health policy planning in the past 10 years of so. It does not address this issue of practice boundaries; but it may well be that the politicians’ and DH’s reasons for proposing this policy is in order to open up primary care to large private care organisations on the Kaiser Permanente model. If that is the case, then they ought to be honest about it. And your organisation would do well to understand this so you can plan your strategy.

I wish you well in your work.

Best wishes,

George

[July 2014: I never received a reply to this email]

www.onegpprotest.org

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Examples of problems  (& this)when patients live at a distance from the practice:

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Why did Andrew Lansley not think this through? I don’t know; neither did Andy Burnham (despite what the DH says about the so-called ‘Choose Your GP Consultation’ from a year ago). Neither of them have examined with any rigour the consequences of ‘choice’ in this case. See my email exchange with ‘Andrew Lansley’.

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For the RCGP’s response to the Government ‘consultation’ on practice boundaries.

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For my email exchange with the King’s Fund.

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The Plot Against the NHS

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Article on practice boundaries with respect to the LMC Conference


Are GP practice boundaries good or bad? My email to the King’s Fund

14/05/2011

I am a GP in Tower Hamlets. I have a particular concern about the proposal to abolish GP practice boundaries and allow patients to register with the practice of their choice, anywhere in England. When my wife and I were interviewed in 1991 to take over a practice that had become vacant, we were asked what we were going to do about the ‘outliers’ on the list. At that time it was regarded as bad practice to have people living at a distance from the practice, and good practice to have a practice population which was close to the practice. In 20 years of practice, in a myriad of ways and on a daily basis, I have seen the difficulties that occur when patients move away and continue to use us as their GPs. Managing people’s healthcare when they live at a distance is more difficult for the practice, more difficult for the patient, and leads to situations that are sometimes unsafe. I am bewildered when I hear politicians and DH people say that practice boundaries are ‘outmoded’, ‘old fashioned’, ‘anachronistic’.

In his closing remarks after a speech by Andy Burnham at the King’s Fund on 17 September 2009, your then CEO said this:

On the plan to make it easier for patients to choose their GP, Niall Dickson said: ‘The vast majority of patients are more than happy with their GP, but the restriction on where they can register is an anachronism and the government is right to sweep it away. There are details to be worked out, but it should not be impossible.’

As you will be aware, this proposal is part of the Health and Social Care Bill.

The King’s Fund says that it ‘seeks to understand how the health system in England can be improved.’ Can you tell me what the King’s Fund thinks at present on this issue of GP practice boundaries (or practice areas as they are also called)? Would abolishing them improve the health system in England? If yes, then explain how.

See Andy Burnham Speech

See King’s Fund Response to Speech

Guardian report of the event


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’.