1. Gross Stupidity or Grand Deception?

This article was published in Pulse on 9/11/12. The following is the text, with minor variation.

I first heard of the politicians’ and Department of Health’s proposal to abolish GP practice boundaries 3 years ago. The policy was trumpeted as a great innovation, giving the English public greater choice and flexibility. All three major parties were in favour; how often does that happen?

But I was bewildered. We have over 20 years’ experience that shows that looking after patients at a distance from the practice (in our case, even as little as 2 miles away) does not work: distance is a barrier to good care, it introduces significant inefficiencies into the system as a whole, and it is at times unsafe. So this policy would lead to a malfunctioning system. (There are countless other systemic problems with the policy, which I will not list here).

The toxic effects of this policy do not stop there. There is the very real issue of list size, and practice capacity. At present, practices serve a local community. There is no doubt variation across the country, but in the case of Tower Hamlets almost all practices are operating at full capacity, if not already exceeding capacity. If our practice were to have patients living at a distance, they would be displacing local patients. So the promise of choice is really an illusion: it is a zero sum game. You want to register with that lovely doctor 4 miles away? Well, he’s already working flat out. He can’t see you, no matter what the DH may tell you.

I starting blogging about this 2 years ago. I wrote to MPs and health ministers, journalists, The King’s Fund, The Patients Association, and others. I got replies from the DH, from the King’s Fund, from an MP. None of the replies addressed the very basic issues raised above. None of it added up.

The argument in favour of the policy is this: choice is enshrined in the NHS; GP practice boundaries are an arbitrary, anachronistic barrier to this choice, a ‘postcode lottery’; abolishing the boundaries will give more choice; it will also introduce competition between practices which will drive up quality. And besides, the people want it: over 75% of the respondents to the Government 2010 consultation on your choice of GP practice said they wanted choice without boundaries.

And yet, to me as someone who has to deliver this, these arguments ignore the stark realities of geography and capacity, and the basic ecology of UK primary care. They are arguments from a parallel universe where the laws of physics are different.

So how can the politicians and the DH be so remarkably stupid? How can they propose a policy that will cause primary care to malfunction, in some cases with real danger to patient health, and which cannot in any case offer the promised ‘choice’? Is the explanation for this crackpot policy down to stupidity, arrogance, wishful thinking, and a misguided collective mindset?

There is an alternative way of looking at this policy, and it took me some time to see this as a more likely explanation to fit the facts. I call this the Grand Deception. I hasten to add that this is a hypothesis, but it makes more sense than the Gross Stupidity hypothesis.

In summary, it goes like this. GP practice boundaries are a barrier to entrepreneurial development. Abolishing boundaries changes the game entirely. If UK residents can register with any practice they wish in England, irrespective of where they live, then large for profit companies can set up chains of GP surgeries in city centres. You have Costa Coffee cafés, now you have Virgin Care GP surgeries next door. They would predominantly attract the younger mobile well. If their patients are sick at home that would not be their responsibility. There would have to be a separate structure to deal with visits. The model itself would cherry pick the patients. This would be very convenient for some patients, but it would not be integrated UK family medicine.

Now how do you achieve this? Let us say, hypothetically of course, that you had a Department of Health that had over time become influenced by the thinking of organisations like the global consultancy firm McKinsey, and other thinking from the US. Let us say the elites at the DH had a cosy relationship with the elites in the think tanks, and organisations like Kaiser Permanente and Virgin Care. It would be natural for McKinsey, Virgin Care, and Kaiser Permanente to view GP practice boundaries as a constraint.

Now you have to have a rationale to change the system, to do away with practice boundaries. So you introduce the idea of patient choice, you say that people are constrained by boundaries, that boundaries are old fashioned. You do not carry out a rigorous, robust risk analysis or feasibility study. You have a national consultation which omits any reference to the problems inherent in this proposal, and a questionnaire which pushes people to answer in a certain way, and then you say that the people want choice, the results of the questionnaire are the proof. And if you can have a docile, compliant press who do not understand the ecology of general practice, and will simply pass on what you tell them, then that’s a welcome bonus.

This is the first of six articles examining different aspects of this issue, and to try to work out if the proponents of this policy are just stupid or actually quite clever, propagating a Grand Deception on the English public, and on Parliament, that so far has been remarkably successful.

Next week, we go back in time to 17 September 2009 and travel with Andy Burnham, then Secretary of State for Health, to The King’s Fund, England’s premiere health think tank.

For additional notes and links to this article

6 thoughts on “1. Gross Stupidity or Grand Deception?

  1. I could not disagree more with you!
    as a patient AND a health professional, I want these boundaries KNOCKED DOWN as soon as possible.
    Lousy ARROGANT AND RUDE GPs are allowed to have me as a patient just because I can’t go anywhere else? where is the good in this?
    Complaining in the NHS always leads to NOTHING but a lot of work/time/money wasted (unless you are complaining about apparent/appaling/proved on paper clinical negligence), you write a thousands complaint letters, go through the ombudsman for NOTHING to change, the rude/useless GPs still having a practice, you being called a ‘difficult patient’. I much rather travel miles to a doctor who IS a doctor and knows how to be ‘with patient’ and not talk TO patient.
    I now chose to have a private doctor, I am in London and she’s in WALES, but she’s the only good doctor I can see who has no boundaries! anything to escape the ROT in the area where I live!

    • I am a patient, carer ,worker ,taxpayer etc. and the current system is far from perfect. However, I cannot be alone in my belief that the current Government is privatising the NHS by stealth. It is quite clever – they just rely on our stupidity. As for private healthcare – anything complex and urgent they have to transfer you to nearest major NHS site (no ITU you see when the routine op goes wrong)

  2. Dear Dr,
    Yes, many of the political and administrative superclass are ideologically opposed to professional independence, and stand to gain financially from the expansion of taxpayer-funded private health-care provision. Yes, this will most likely lead to a US-style devil-take-the-hindmost system. Yes, from this perspective the Patient Choice policy looks like the thin end of the wedge.
    Equally, the current system is not perfect. For all that policy-makers may do to undermine it, it often delivers excellent care; but by no means always. Suppose it works wonderfully-to-tolerably 80% of the time. That still means that 20% of all patients experience rough justice, or rough medicine: many millions of people. Those people are strongly motivated to support any moves that stand some chance of mitigating their problem. The 80%, meanwhile, will not focus too closely on the relevant policy debates.
    In these circumstances, how sensible is it to resist any divergence from current practice? How likely are you, as a matter of practical politics, to be able to ‘hold the line’?
    Moreover, I’m sure that if it could be avoided you would not wish to see perpetuated a situation where a significant number of patients really cannot get their needs met. In which case, you and like-minded colleagues may wish to come up with some amendments to the current system which, while maintaining the overall integrity of the model, nonetheless improve the lot of specific disadvantaged groups.
    As an illustration, consider Post-Polio Syndrome. PPS sufferers are a dying population. In insurance-based systems, e.g. Australia’s, that matters less than in the NHS. Here, a few units in teaching hospitals have carved out a research specialism with some connection to PPS, e.g. sleep apnea; but the consultants there are hardly interested in the Syndrome as such. After all, the medical input that actually helps PPS sufferers is typical GP stuff: supporting and guiding the patient’s own incremental efforts to mitigate the effects. Of course, most GPs have little time or inclination to discover much about a Syndrome that affects such a small proportion of patients. So: many PPS sufferers receive remarkably bad treatment; others refuse to go near the health service until in dire straits. But there are a few GPs who, for one reason or another, have learned how to address the problems of PPS.
    Surely, that small group of GPs could be recognised, and PPS patients could be allowed to establish a relationship with one of them. It might be a little untidy, but it would be a pragmatic solution. What do you think?
    Best, wishes

    • GPs are generalists. If a patient of our’s has a rare disease, we learn what we need to know to manage that patient in primary care, this does not take long. As you say, ‘it is typical GP stuff’. If they truly need specialist care, then they may need a specialist (this usually means a hospital-based team) who will advise on management and offer appropriate support. In the end, there are two non-negotiable realities (in the sense that gravity, at least in our world, is a non-negotiable reality): one is that looking after patients at a distance does not work in the UK primary care model for a variety of reasons (yes, it might work for some patients some of the time, but as GPs we care for all of the patients all of the time); and the other is the issue of capacity: GPs are working flat out looking after their local populations, they are unable to look after additional patients (inefficiently, unsafely) from neighbouring areas or even further afield.

  3. I live in North East London – I have 3 practices in my catchment area – all of them bad. One one occasion I ended up at A&E because I could not wait 4 days to see doctor. And no, calling at 8:00am does not work, it’s more like lottery – by 8:01 all same day appointments are taken. No wonder if there is about 10,000 patients per practice (not joking). There is practice with fewer patients and !!!closer!!! to us (!! – 0.67mi) but we are not in the catchment area, therefore we are unable to register there. Where is the sense? And when lived in Oxford there was no problem at all being registered and visiting doctor 3.5 mile away – no problem at all for almost a decade so I can argue that the catchment area is good. It is not. Something needs to be done about it. If not scrapped then at least catchment areas to be a lot bigger, because 0.67mi is not a distance, and in fact is closer than 2 of the services in which catchment area.I am now. Any constructive argument on that welcome…

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