The Department of Health’s ‘reply’ to my email to Jeremy Hunt


In mid-February 2015 I emailed Jeremy Hunt raising concerns about the policy allowing patients to be registered with participating GP practices even though they live outside the practice area. The policy was implemented on 5/1/15. It is a deeply flawed policy which sounds good on paper (unless you understand how general practice works), but when transferred into the real world is a mess. (It is as though someone asked an architect to actually build a building according to an Escher lithograph).

Just one of the problems in the real world is to provide cover for patients who get sick at home and cannot travel to see their registered GP. (A patient registered with a local GP would walk to their GP or, if unable to leave their home, be visited by their GP). So NHS England area teams were given the Herculean task of organising this cover. The October 2014 launch of the policy was put forward to 5/1/15 because they had not yet put in place the infrastructure for this cover. What I discovered in January 2015 was that there was still not blanket cover across England; in fact in London there was effectively no cover. So the situation was unsafe for London patients registering with a practice at a distance from their home.

This is the reply I received from the Department of Health:

Our ref: DE00000920945

Dear Dr Farrelly,

Thank you for your correspondence of 15 February to Jeremy Hunt and Norman Lamb about GP practice boundaries. I have been asked to reply.

As you are aware, the GP contract agreement for 2014/15 brought in a measure allowing GP practices to register new patients from outside their traditional boundary areas without a duty to provide home visits for such patients, as they previously had to do.

With this change, provisions such as home visits need to be in place for patients should they need urgent care at or close to home and cannot attend the practice they are registered with. NHS England is responsible for making sure this happens. Its area teams are currently working with GPs and the NHS 111 service to make sure these services can be provided.

As you are aware, it was originally planned that the measure would come into effect from October. However, in order to allow its area teams more time to put services in place, NHS England took the decision to put the date back to 5 January. It believes that this decision was in the best interests of GP practices and patients.

I note that you have written to NHS England directly about your concerns. I hope that you receive a response soon.

Whilst I appreciate that this may be a disappointing reply, I hope it clarifies the situation.

Yours sincerely,

[I have removed the name to protect the innocent]
Ministerial Correspondence and Public Enquiries
Department of Health


Attentive readers will notice that this is a non-reply. This is typical of replies I have had from the Department of Health: a bland, entirely unnecessary, description of the protocol but ignoring entirely the issue of patient safety and the proper working of this policy.

I did in fact email NHS England (they were copied into my email to Jeremy Hunt as well), but I have not received a reply.

If abolishing GP boundaries is such a good idea, why won’t the Department of Health answer some basic questions?


I have written on three occasions to the Secretary of State for Health, Jeremy Hunt, copied to the Health Select Committee members (and miscellaneous media outlets) about some very basic problems with the Coalition Government’s flagship policy to abolish GP practice boundaries.

On each occasion, I have had replies from the Department of Health. None of these replies have remotely addressed the warnings I have raised.

It is as though an able seaman were to send an iceberg alert to the officers, and receive in reply the rota for cleaning the toilets on Deck C. Not once, but three times…

In the third reply, the Department of Health official writes:

“I note that you have contacted the Department of Health previously on a number of occasions about this issue.  The information given to you by my colleagues is the most up-to-date and accurate available, and there is nothing further I can add to this.  The Government’s position remains as set out in previous letters.I am sorry if this is not the reply that you were hoping for, but as there is nothing further that the Department can add, we must now consider this matter to be closed. ”


First email to Jeremy Hunt

Department of Health response

Second email to Jeremy Hunt

Department of Health Response

Third email to Jeremy Hunt

Department of Health Response


NHS England have done no better; see their reply, and my second attempt to get them to answer my questions.

My concerns about the ‘independent evaluation’ of the choose your GP practice pilot


I have written to the current Secretary of State for Health, Jeremy Hunt, about my concerns about the proposed policy to abolish GP geographical boundaries. To my first email, I received a non-reply masquerading as a reply and so I sent a second email. The reply to this second email was no better than the first and in fact covered much the same ground as the first reply. So I have emailed him again today. (I have sent similar emails to NHS England and the CQC; NHS England’s reply was wholly inadequate so I have written to them again).

The replies I have received so far have limited themselves to describing the structure and process of the Pilot (which ran from April 2012 to April 2013), and the fact that an ‘independent evaluation’ would be made, and sent to the relevant bodies, including the GPC and NHS England (who have inherited the responsibility for implementing (or not) this policy).

I have been sceptical about this policy from the beginning, and my scepticism has if anything grown over time. The policy sounds attractive at first sight, but to anyone who knows how general practice in the UK works (its ecology), the policy does not make sense. The Department of Health so far have promoted this policy assiduously, ignoring the problems and risks. The 2010 ‘consultation’ was a PR exercise, structured in such a way so as to get the desired result, a New Labour ‘dodgy dossier’. The politicians and Department of Health have since used the ‘results’ of this rigged consultation to continue to push for this policy.

The Pilot structure did not actually test the policy itself in any true sense. I wondered how the evaluation would be structured: I thought it likely that it would avoid evaluating the policy itself.

I contacted Professor Nicholas Mays of The London School of Hygiene and Tropical Medicine, and Director of the Policy Research Unit in Policy Innovation Research who were commissioned to carry out the evaluation. I asked Professor Mays if I could see the ‘spec’ the Department of Health had sent them; he did not have such a document, but sent me the Evaluation of GP practice choice pilots, Proposal, 14 May 12 that he had submitted to the Department of Health in response to their request. He suggested I contact the Department of Health about the specification and so on. What I found out was that the Proposal was the result of a meeting between Department of Health officials (I do not know how many) and Professor Mays (I do not know if other members of the Policy Research Unit were present). The Pilot was discussed at this meeting, and the Proposal resulted from this discussion. The meeting was not minuted. So no written ‘spec’.

I read through the Proposal and it confirmed my fears. The evaluation was designed to assess the Pilot rather than the policy. This sentence is from the first paragraph, under the heading ‘Rationale’:

“According to the Department of Health, 75% of patients who responded to a recent consultation on GP choice made it clear that they wanted greater ability to register with a practice of their choice irrespective of its location.”

This is the ‘consultation’ which I say is rigged. Has Professor Mays read the consultation documents and assessed how this ‘75% of patients’ was engineered?

Further along in the Rationale section is the following:

“People able to access GP services in the pilot areas will have greater choice and flexibility about the GP practice that provides their personal care. It will mean patients are able to register close to work, close to a relative they care for or even close to a child’s school.”

This detail, ‘even close to a child’s school’, bears further scrutiny. It was one of the avowed benefits of the pilot (and therefore the policy) in the Department of Health’s media launch in December 2011. I wonder if the evaluation will scrutinise this detail. Will it ask if this detail, registering with a practice near a child’s school, actually makes sense? What benefit accrues from this? How does it work? Are there any risks? Did Professor Mays’ team ask these questions, or did they just take this as a given?

I replied to Professor Mays as follows (19/10/13):

“I have now read through your Proposal for the Evaluation of GP practice choice pilots. It confirms what I feared. Your evaluation does not actually scrutinise the policy itself. I am not criticising you or your team but I think the DH has given you a brief which means that you avoid asking some very basic questions. I am sure that you have done good, thorough work, and I am sure you will come up with some interesting and useful insights; but it is likely that your ‘evaluation’ will miss the basic, fundamental flaws of this policy. These flaws are not exposed, revealed, by the ‘pilot’.

I attach my Submission the the Health Select Committee of May 2013. It outlines what I see as the main problems, I hope in a clear way. I suggest you and your team read this document.

What I am saying is that this policy has been promoted without taking into account the problems, the side effects, the unintended consequences, and it would appear that this has been done intentionally, wilfully. When thalidomide was launched in the late 50’s, it was marketed as a wonder drug, and there were real benefits. But there were also very considerable problems, which emerged with time.

Your evaluation will, by its very design, concentrate on the benefits of thalidomide, the marketing and distribution strategies of thalidomide, but not with the unwanted side effects.

I know what the problems are with this policy, I deal with them on a daily basis, and what I have outlined in my Submission is just the tip of a large iceberg.

I would be happy to meet with you to discuss this further, if you think that would be constructive. I am copying this to the GPC.”


I have not yet been able to see the final report that was sent to NHS England and the GPC. Professor Mays has told me it is being peer reviewed and then will be available, perhaps in the next month or so. Once I have read it, I hope then to meet with Professor Mays to discuss this further.

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


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.


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




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.