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.