Diary April 4th

Monday April 4th

The morning was spent organising painters and a plasterer as we are doing decoration of 5 rooms of our house starting with the sitting room and conservatory. Quite boring for a diary. The main thing for today was that the minister of state for health, Andrew Lansley came to the commons to make a statement about having a pause for the dreadful new health bill he wants to get through which could end up privatising large elements of the NHS. I have been writing loads of letters and submissions about this. I have followed the bill’s progress closely and below is my submission to the scrutiny committee:

1. I worked as a general practitioner in Castleford from 1978 until 2005. Throughout most of that time I was deeply involved with postgraduate general practice education and worked as a GP trainer; vocational training scheme course organiser; continuing medical education tutor and an associate director of postgraduate general practice education at the Yorkshire Deanery. Towards the end of my general practice career I worked part time for our Primary Care Trust, now called NHS Wakefield. I managed the education courses as well as the appraisal scheme for approximately 250 general practitioners. I was responsible for the training and development of 17 appraisers. I also dealt with underperforming and ill GPs. I was an appraiser myself as well as a quality outcome framework medical assessor and mentor. I retired from the PCT job at the end of May 2010. My qualifications are MB, BS, BSc, PhD, FRCGP and I have a post graduate certificate in primary care education.
2. I would like to outline what I feel my “relevant expertise and experience” is before informing the committee some factual information about general practice in the Wakefield District and then my views. During the many years I was involved with the training of prospective G P’s I taught communication skills both one to one and on an annual deanery summer school. I was an assessor of consultation skills. For several years I was tutor in ethics on a deanery summer school. When I was a course organiser I had to visit and inspect many training practises. More recently as an appraiser and quality outcome framework assessor I visited about 26 practises a year. Undertaking an appraisal could take up to 3 and of conversation with a general practitioner discussing in depth his or her work and plans for the future. No one is disputed that in the last six years of my work for the Primary Care Trust that I met more general practitioners than any other person working in this area. As the PCT’s appraisal lead, each year I read approximately 250 GP appraisal documents and made a note of each personal development plan.
3. This paragraph is about my ethical concerns. I was a very reluctant fundholder when this was introduced and resisted cooperating until we were forced because financial resources were being taken away from our practice. The reason I was anti fundholding was on ethical grounds. I could see savings being made by practices referring less to secondary care, prescribing cheaper drugs and are undertaking less investigations. It is obviously good practice to honesty look at referral patterns and see if the result of this indicates inappropriate referrals that could have been dealt with in house. It is also good practice to look at prescribing patterns and rational prescribing which could mean prescribing a similar drug that costs less. I am sure the fundholding created a conflict of interest during the consultation. One GP told me that he was telling patients they could no longer have a particular drug and that the government had instructed him to prescribe an alternative. When I pointed out to the GP that this was unethical he simply agreed and continued with his approach. At the time of fundholding I was a disability living allowance assessor. I was appalled that some of the patients I was assessing were not being referred to secondary care. Savings made by fundholding practices could be used to benefit the patients and also to build on to surgeries to provide extra space. There is nothing wrong with that but GPs generally own the surgery buildings and therefore are able to sell the building either to remaining partners on retirement or to a private company and realise very significant profits. I can see a similar situation arising if the bill is implemented. Section 223L (1) states “the board may after the end of the financial year, make payments to commissioning consortium if, in the light of an assessment carried out under section 14Z1, it considers that the consortium is performed well during that year.” Section 223Z (7) states “A commissioning consortium may distribute any payments received by it under this section among its members proportions as it considers appropriate”. I am grateful to Alice Miles writing in the New Statesman on the 7th of February, 2011 for pointing me towards this part of the bill. This reminds me very much of the ethical problems I saw with fundholding. The members receive money from the board and if the rule is that this money should be used to improve patient care then I can see buildings being expanded again and profits taken from this. I cannot see a surgery building owned by GPs extended and that extension owned by another body.
4. I would now like to inform of some of the activities of general practices that I have observed and heard about in this area over the past five years or so. One or two practices (and these were dedicated fundholders in the past) have created huge businesses by purchasing the buildings of small practices and employing GPs on a salaried basis. This has resulted in the absence of some of the partners from their base practice in order to pursue business or clinical activities in these purchased surgeries. The situation has caused one partner to move from one of these practices to another in order to continue with the excellent clinical care he wants to provide without having to deal with business affairs. The majority of GPs in this area are like him. Another practice has an operating theatre and secondary care consultants provide a service there which on the one hand is a good thing for their patients but on the other hand is diverting secondary care clinicians from their base. I have no idea what the financial arrangements for this are but I am worried about a conflict of interest here when the practice is involved with commissioning decisions of its consortia. I know that all these activities are allowed under the rules and are within the law. A few GPs make huge profits whatever system of primary care organisation is in place. These same few general practitioners who profited from fundholding, primary care groups and trusts and are now becoming seriously involved with the consortia.
5. I mentioned above that I was responsible for managing the appraisal scheme for NHS Wakefield for 6 years. Annex 1 is an extract from my fairly recent annual appraisal report (2009/10) which I believe was presented at a meeting of the PCT’s Board which was open to the public. These are examples of what GPs want to focus on in their learning plans. I did not have to remove anything for confidentiality reasons. “Maintenance” means “keeping up to date”. You can see from these, which are representative of the learning plans of the whole group, that the focus their education not on business matters but on clinical matters. It is to be noted that one GP put “let go of management” in his or her personal development plan.
6. The people I worked closely with for six years at the PCT were hard working, loyal and had the improvement of patient care as their main objective. I had two line managers, who were directors, one of whom was an ex midwife and the other worked for one day a week as a general practitioner. Part of my job was to deal with underperforming and ill general practitioners. I worked with each of these two directors on this. This was complex time- consuming work and required knowledge of employment law, the General Medical Council and the National Clinical Assessment Service. In the past there was the Local Medical Committee’s Professional Support Group of which I was a member. This attempted to do similar work and the members undertook this work voluntarily. Meetings had to be in the evenings and we had a senior member from the health authority to guide us. That work was amateurish compared with the approach of the Primary Care Trust. The expertise to protect the patients from underperforming and ill general practitioners will disappear on the abolition of the PCT’s. This is just one example, as I see it, of the consequence of the new proposals. Both of these are directors have left the primary Care Trust, one to work in secondary care and the other returning to fulltime general practice. There is no one working in this area with that experience or expertise. I could give other examples of a highly skilled and experienced people are leaving or planning to leave in the near future. The Primary Care Trust was a model employer with an excellent human resources department. I am afraid to say that many general practices are certainly not model employers or as good managers and I am worried that this will be reflected in the activities of consortia.
7. I am a member of the British Medical Association and proud to be a Fellow of the Royal College of General Practitioners. Of each of these bodies are representing my worries and I know each will be giving evidence to you. I feel so worried about the future of the NHS as a consequence of implementation of this bill. . I am not sure how much weight the committee gives to the views of individuals. However, the title of the guidance for submitting evidence is entitled “now have your say” he and I feel I have done that. I feel I have addressed matters contained within the bill, concentrated on issues where I have a special interest or expertise and included factual information of which I want the committee to be aware.
I watched the Minister of State for Health’s statements and the questions that followed this afternoon. Towards the end of all this a labour MP asked a question that was obviously very hostile. Mr Lansley answered that the MP should talk to Stewart Findlay who is the lead GP in Northumberland. Stewart is married to my second cousin Lorna and they live next door to William Hague. When we meet we leave talking about the NHS to just before we are leaving as we have such opposing views. I have emailed them to tell them I am embarrassed at having someone in the family with such views but in order to maintain family unity I will not tell the opposition all I know about Stewart. Actually, he is a very nice bloke and like us, has a property in Italy. Here is the Hansard entry:

Grahame M. Morris (Easington) (Lab): I would like to thank the Secretary of State for single-handedly destroying the Government's reputation on the NHS through this Bill. No amount of minor changes or slowing down of the pace will address the Bill's fundamental failure to protect the public from privatisation by stealth. If he refuses to resign, is he worthy of his nickname, Broken Arrow-he doesn't work and he can't be fired?
Mr Lansley: The hon. Gentleman might like to talk to Dr Stewart Findlay, who is among those leading the pathfinder consortium in County Durham. He might like to talk to people locally who are piloting the new 111 telephone system, which will give better access and better urgent care to patients. Instead of sitting there making rather absurd political points, why does he not go and talk to people who are delivering services to patients? That is what the NHS is really about.


I am very pleased that Shirley Williams has come out against this bill. She is very articulate and incise and I have great respect for her.