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A faulty production line

'If you want to vent, don't do it in front of a trainee'

Two GP trainee guest editors of Pulse spoke to RCGP chair Professor Helen Stokes-Lampard about criticising general practice in front of trainees, the College’s support for the GP Forward View and why chairing the College is like walking a tightrope in high heels

Dr Helen Stokes-Lampard – 3x2 – online

Dr Helen Stokes-Lampard – 3x2 – online

Dr Nishma Manek: There’s a lot of negativity around at the moment. That can feel quite hard for us and trainees often question whether they’ve entered the right profession. What would you say to them?

Professor Helen Stokes-Lampard: The negativity is probably the worst I’ve ever know and that’s tragic because it’s putting people off doing what, to my mind, is the greatest job in the world. Being a GP on a good day, in a surgery that’s properly resourced and properly staffed is fantastic; that richness of the relationship with patients, what you can do for people and to be part of the community is so amazing. That’s why I do it, and that’s why most of us do it.

The negativity is a consequence of a whole decade of under-investment and under-resource and so it’s understandable. But it’s not helpful. What I try and say to my colleagues is of course we all need a safe space to vent when you’re feeling negative and feeling down but talk to a senior colleague or get some external help. Don’t vent at a trainee. When you’re having a good day share that with a trainee, be inspiring for the future because we know the pendulum will swing back again.

NM: I couldn’t agree with you more. So when we think about our future as GPs how do you think that’s going to be different to how it’s been for you as a GP? It feels like we’re in a real state of change at the moment and I’m not sure what that’s going to look like for us.

We are in a state of change, that’s right, but general practice has always been changing. Looking back at the past, there’s always been a crisis in general practice, there’s always been GPs frightened about the future. But patients’ need for a trusted health care professional is constant.

I think what will be different is the way that we work. We’ll be working in larger and larger groups. When I started as a GP trainee the average size of a practice was 6,000 patients. Now it’s about 10,000 patients but I know of some amazing practices that have got 150,000 patients in them, but there are still those 1,000-2,000 patient practices as well.

There will be partnerships but that will be one of a range of ways of delivering care. The partnership model is a very powerful way of delivering care but it’s not the only way and that’s something that’s changing all the time. Some parts of the country have lost the partnership model completely. In others, it is fantastic and probably the only way of delivering care. That will change.

We’ve already seen a large proportion of the workforce choosing to be salaried but there is a swing back with younger GPs wanting to be partners again. That’s great to see.

helen stokes lampard paul stuart

Dr Helen Stokes-Lampard – 3x2 – online

Dr Heather Ryan (left) Dr Nishma Manek (centre)

Heather Ryan: You told the House of Lords that you consider that the partnership led model of general practice was not like to be fit for the long term future. The College clarified your views, saying you supported partnership and you thought that the independent contractor model should be nurtured and maintained. So why should we nurture and maintain something that you don’t think is fit for the long term future?

I was being asked about a much bigger issue and my actual sentence was along the lines of ‘I love the partnership model but the current model is not fit for purpose in its current context because newer doctors are not choosing to be partners, we can’t fill the vacancies’.

The partnership model need to flex. We need to fix issues like premises challenges and last partners standing issues and then suddenly partnership becomes far more attractive. There is also opportunities in working at scale: I’ve seen one model with clinical partners, managing partners, researching and teaching partners. Those kind of things need to be looked at.

However, I do believe the partnership model in terms of GP ownership and management is incredibly powerful. It’s a driver for change because GPs are fundamentally creative and when you run a business you can run it at a pace that you want to. If I go into the surgery and say ‘these blinds are scruffy I want new blinds’, we’ll put new blinds in. In a hospital, if you want new blinds it’s probably got to go through four committees and a procurement process.

However, we’ve got to be realistic that we can’t stick just to the old ways of doing things.

HR: Last April, when the GP Forward View was published College hailed it as perhaps the most significant piece of news for our profession since 1960s. What are your feelings about the Forward View now, and in retrospect would you have responded to it initially different?

Firstly, I wasn’t chair of the College when we responded. However, I agreed that the GP Forward View announcement was the most significant announcement for general practice since the 1960s, because actually a promise of £2.4bn a year from 2020 onwards is massive; a promise that at least 10.5% of NHS resource will go into general practice, bearing in mind last year it was only 8.3% of NHS resource, that’s massive; and 5,000 more GPs, 5,000 more other allied health care professionals, that’s massive.

Those are significant and I wouldn’t roll back from that. Quite different from a promise, however, is delivery on a promise. I was appointed to hold people to account and to ensure that promises are delivered on, to at least be watching and pointing out when things are, or are not being delivered on. The first thing I asked Council for when I was elected was their permission to conduct the interim review.

Out of the 12 clear deliverables that we could identify for that first year, we rated three red, three green and six amber. That’s really not great.

HR: The College have been calling for quite a long time for training to be extended to four years. Does that mean that actually the current three year training pathway isn’t fit for purpose?

GP trainees are telling us many of them don’t feel ready to commit to a career in general practice following their training because it hasn’t been enough for them. They’ve loved the clinical stuff, they’ve ticked the box, they’ve jumped the hurdles. They are safe, but they’re not robust or resilient enough. They haven’t got the experiences they need to take flight, to soar. They feel they’re still learning a lot for a while to come.

In 2008, the Tooke report suggested GP training needed to be extended significantly. The College undertook a big campaign to extend training by 2012. I was there in the office when Clare Gerada danced around the office because all four nations of the UK had agreed that GP training needed to be extended to four years. We thought it was sorted.

helen stokes lampard 330x330

helen stokes lampard 330x330

What happened was a review called the Shape of Training, which was to look at the whole of medical post-graduate training and that put this into the long grass. It got delayed, and then at the end of last year we heard that ‘actually, sorry you can’t have four year training, you can have three years plus fellowships after training’. We’ve got those already in many places and we know it’s not enough because, once you’re in the workplace, priorities change and service commitments comes in.

Council has not yet decided whether it’s pushing for four years or longer - but it is going to push for at least four years. That will include at least two years based in general practice. For those who are able to go through the same pace and go through their exams in the timescale we hold them to, great. We want people to get the hurdles out the way, prove their clinical competence, get their MRCGP, so that fourth year is a time to be enriching your experience to fly, to do leadership training, to learn more about mental health, to being much more understanding of commissioning or practice models, of leadership, of partnership working.

NM: Do you think our training prepares us well enough for partnership though because it doesn’t feel like that to me?

It’s interesting because people have said they haven’t been told about partnership models, practice accounts or stuff like that. I remember very clearly having sessions with my trainer talking about the difference between salaried, being a partner, the implications for your pension. I sat there towards the end of my training with the practice accounts and he went through it and explained to me how a practice business runs.

I’m sad when I hear that’s not happening and partly it’s not happening because the programme is crammed full - it’s relentless, the amount of stuff you’ve got to do. The e-portfolio didn’t exist back in my day. It is different and we are cramming so much in. Something has to fall off. I’m saddened with this - it means people don’t feel ready for it because they don’t know enough about it.

NM: You’re almost up to your one year anniversary of being chair and it’s been a real whirlwind. You’ve had to be chair at a difficult time politically, financially, professionally. What’s been the hardest thing, what have you enjoyed the most and how’s the last year been for you?

The best bit is the people I get to meet. The GPs, the trainees, the medical students, the college staff who are almost universally amazing and wonderful people doing their best to do an amazing and wonderful job.

I’ve been reflecting on the good bits and the bad bits and I reckon it’s about an 80/20 split of being an amazing job and being a really, really grim job. The difficult stuff is the personal insults, or personal slights of things which are not personal at all, whenever I’m reflecting a college view or I’m trying to reflect a member’s view. Developing that thick enough skin to deal with real nastiness and personal vitriol.

One really powerful strategy that I picked up is the dealing with trolling and dealing with nastiness on social media and so I just don’t engage. If you’re anonymous you won’t get a reply from me on social media. If you’re a professional who has something to say, I care. I may not agree, I’d respect, I reserve the right to have a professional disagreement but I care if you’re prepared to own your comments. That’s been helpful and that’s particularly powerful with online forums you get all sorts of nonsense. Dr Anonymous thinks you’re stupid - well Dr Anonymous you don’t exist in my world.

Also, everything I do or say is a tight rope because I’m trying to represent 52,000 GPs and they’ve got 52,001 views. But also I have to have conversations with senior politicians. If I want to get in the door of Number 10, if I want to be sitting down and having a meaningful conversation with the health secretary and if I want to be having a meaningful conversations with the devolved nations leaders I have to be respected by them, and I have to respectful of where they’re at.

That doesn’t mean colluding with them. That doesn’t mean pandering to them. That doesn’t mean throwing fresh paint around when somebody big and important is coming to the College. It does mean being respectful and being professional and distilling what I hear from members which is sometimes very angry and embittered and turning it into a professional message.

Now as GPs we do that all the time; we transform information into something people can understand and so that’s what, that’s what I spend a lot of my time doing here but I am conscious it’s like walking a tight rope in high heels.

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Readers' comments (7)

  • HSL comes across well towards the end here. Howvber, I do feel that trainees need to be exposed to the full effects of funding on GP and now the new models of care can impact on certain practices unable to accommodate it.
    To censor younger GPs from the full nastiness of general practice will do nothing for their development. They need to grow into their role without being protected and take on the work head on, so they can learn what they should be doing in a 4 or 5 year training course in their first few years post CCT. Leadership and commissioning can come later.

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  • "...we know the pendulum will swing back again."

    No, we don't. This is where I fundamentally disagree with HSL. Yes, patients will still need to be seen, but it won't be GPs as we know them seeing them. Think I'm wrong? Look at OOH: most of the work is now being done by ANPs and paramedics where I am, and GPs are very thin on the ground. Our profession is disappearing.

    I also don't think GPs are going to be allowed to be in the driving seat for the new corporate-style superpractices. There's too many powerful vested interests waiting in the wings, and they have very skilled commercial lawyers. There's no way we'll be able to stand against that. Think I'm wrong? I know of situations in the US where lucrative healthcare contracts were fought over, and passed backwards and forwards on repeated appeals, for so long that the whole process had to be scrapped and restarted.

    I've also got direct experience of a US style healthcare company. I was bullied and harassed, on both clinical and non-clinical issues, by several levels of managers. They blatantly had no idea about a physician's professional obligations, and did not put patient care first. And PAs are a gift to those people: cheaper, less experienced, easier to replace...

    To think that somehow we will magically bounce back from this ever-deteriorating situation is painfully naive. While you're trying to engage with government and their proxies, the ones really in charge of this nightmare (the ones with powerful friends and promised rewards) are laughing at how gullible we all are.

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  • Just realised why HSL is so optimistic- she states she doesnt read anything by anonymous authors. She shows a wonderful understanding as to why NHS professionals often choose to write anonymously these days. Being anonymous doesnt mean that you are making your opinion up, I wonder if she also ignores anonymous whistle blowers? If she does, is that not negligent? and if she doesn't does that not imply a degree of hypocrisy? Also if she's not reading these comments why are they moderated? She just stated that these authors don't exist in her world..... in which case can she be a bit more honest when she states she represents 52000 GPs, she certainly doesnt represent me. And as this is a pseudonym and I therefore 'don't exist' can she bring her total down to 51999?
    Actually, I think her opinion is that ignoring anonymous comments isn't a powerful strategy at all, I think picking up random ones and detailing why she disagrees with them would be more useful at engaging with those GPs who as a group are disengaged from the RCGP, turning around their opinion would be an impressive mark of leadership, her current 'powerful strategy', well anyone can do that. The sticking the head in the sand is not winning over sceptics, merely reinforcing their negative opinion, not of her personally, but of their belief in her ability to make meaningful change for the better. HSL wants people to identify themselves, I understand and respect that other GPs might wish to remain anonymous, given todays political environment so why can't she?
    I found the use of the phrase 'real nastiness and personal vitriol' again a reminder why I use the phrase- 'we choose to be offended'- at her level she shouldn't be taking things personally, and again she seems guilty of hypocrisy for, on one hand, not wanting frustrated colleagues at the coal face to vent in front of their juniors and telling them that they should do it at their seniors, yet on the other hand, when some contributors do exactly what she wants and they express it directly to the top (when comments are directed at her) she ignores it if the depth of frustration felt by the contributor is such that it is expressed with anger/ disrespect? (Even though she also states in this article that she appreciates some members are very angry and embittered) I was taught a long time ago that respect was earned, through action. HSLs views expressed here, and of several of her predecessors,remind me why I lost faith in our leaders and why I emigrated. I am much better off elsewhere than in the UK under the current leadership. How long was I supposed to wait for the pendulum to swing back? (I don't think it will in the next 15-20 years) If HSL couldn't inspire me to stay, how was I supposed to inspire trainees to do what I wasn't prepared to do myself? I led by example.... took action, and left. I could happily persuade young trainees to move to my current practice, I can't recommend they leave to work in the UK.
    On a separate note..... if there were 3 men in that photo shoot would anyone be claiming that women were being under-represented in the RCGP? Not exactly a gritty feet to the fire interview.... more an opportunity to give her views...... again..... Dear Ed, the interviewers asked four questions, but they didn't interrogate the responses about a follow up article asking her to reply to readers comments?

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  • Vinci Ho

    To Madam ,with love
    (Inspired by Sir Sydney Poitier)
    Dear Chair,
    First of all , you do not need to reflect on this comment as I am never a member but at least I am not anonymous.
    It is my opinion that you were a breath of fresh air when first being elected just over 12 months ago. My expectation was perhaps you could be the charming girl who pointed out to everybody that the emperor was in fact, wearing no clothes instead of new ones. Being disappointed so far , one would still want to give you the benefit of doubt on a learning curve.

    It is a fact that there is much negativity circulating in our profession and will become unhealthy to our young colleagues. To do 'something' about this is politically correct.
    However , there is a difference between treating the symptoms and the origin.Surely ,you are well experienced for this argument as a senior colleague in general practice.
    ''Every matter has its origin and final form ; every event has its beginning and the end . Only if one understands what comes before and after , the 'great way' is near to be acquired.'' Great Learning
    All these negatives we are talking here did not develop in one day with no explanation. And they are not confined to the older colleagues and those teaching our trainees . Think about how our younger colleagues felt after their defeat by the government on their industrial actions in more than one occasions. We are at war , precisely war of politics , with the government . The day our longest serving health secretary in history said he was not 'picking a fight with GPs' , this war was declared . His infamous comment of underfunding GP was a 'penance' of our contract in 2004 , demonstrated his belligerence towards this profession. Frankly, we are not traditionally trained for fighting a war like this as we only want to look after our patients , rather than involving in politics. Not knowing how to tackle these politicians with undoubtedly hidden agenda(s) had led to this vicious cycle of negativity. We looked up to the ones elected to represent us but they were too stuck in a political ambiguity by a baggage of staying politically correct in front of the public . The words ' no better time to be GPs' were exploited by the previous prime minister in House of Commons and his conclusion was 'crisis , what crisis?' Then our well established medical journal published an academic study of investigating the pattern of mortalities between weekdays and weekends. This was immediately hijacked by our clever health secretary and this provided the basis of the seven days GP opening policy (without extra new
    investment of resources). It is not surprising BMJ is so much politicised and anti-government in tone these days.
    The ideal politics in a war is the type which requires the least amount of physical conflicts.
    In Chengdu , China , there is a couplet posted on the wall outside a temple paying tribute to the arguably most intelligent military strategist in Chinese history,Zhuge Liang(諸葛亮). Those who had played video games(or watched films)involving the famous Three Dynasties period(184/220-280 AD) would be familiar with him .
    The couplet read :
    ''Playing the mind-games properly , the enemies would self-neutralise by itself .
    It is well known through history that soldiers do not really want to be belligerent.
    Without a throughout analysis of the current circumstances , either a flexible(liberal) or harsh(restrictive) strategy will create mistakes .
    Always rule my country(Shu) with careful consideration, not once , not twice but thrice.''
    The mind games this government had played on us were numerous and it is time for playing ours . The good news is this government is weakening and zombified .
    From Capita to Sustainability and Transformation Plan (STP) , resilience funding to premises support etc , the word hypocrisy only kept repeating itself . The caveat of genuinely hurting our patients has become more and more plausible.The careless whisper of 'Public sector workers are overpaid' revealed the true mentality of a government willing to sacrifice people's well being for better economy and GDP rise.
    Winston Smith worked for Ministry of Truth in 1984 but never really wanted to lose his soul and true identity . He was not allowed to show any negativity towards the establishment and his fate was clearly sealed with a drop of melancholia.
    Even the government's own propaganda media and organisations have been exposing negative 'facts' .Based on objective facts , we can make subjective comments. I believe that is what we have been doing on this platform, even though you may not like the negative tone of them. Making no mistake , we are not deluded that these comments represent the opinion(s) of the majority. Certainly , we condemn character assassination as it represents verbal abuse and violence. The level of anger and frustration amongst all medical frontline workers is historical and phenomenal . This is also true to those who care about domestic issues and social justice in this country.

    Watched The Good , The Bad and The Ugly(1966) again after 40 years. What inspired me the most was the poignant speech of the Captain of the Unionist in last part of the film against the backdrop of the brutal civil war:
    Soldiers on both sides were reek of alcohol and really did not continue fighting. It was only a bureaucratic argument from the 'headquarter' that his army had to defend this bridge connecting to their enemies , no matter how many soldiers died as a result. He wanted to bomb the bridge but he did not have the guts to disobey the higher order. So the Good(Blondie) and the Ugly(Tuco) blew up the bridge and stopped the two sides fighting as they themselves wanted to get hold of some gold coins on the other side of the river. It was all about self interest ultimately whether you were good , bad or ugly. After the bridge was blown , the first person the Good came across was a young , not old , soldier dying of his fatal wounds.......

    As far as those who are still respectably enthusiastic about training our younger colleagues, I quoted what was said in To Sir, with love (1967):
    Barbara Pegg: Well, Sir, you're like us, but you ain't, I mean, you're not. It's kinda scary, but nice. You know what I mean, don't you?
    Mark Thackeray: Well, I... I don't know how to answer you, except to say that I teach you truths. My truths. Yeah, and it is kinda scary, dealing with the truth. Scary, and dangerous...

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  • Prof Helen has a challenging role. Her studied optimism is encouraging and useful.IF NHS England does arrange 10.5% of NHS funding to Primary Care then resources will align reasonable activity, if not then workforce and morale will deteriorate.

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  • What she is saying is if you really want to vent, use the WC. Trainees should not get wind of the true situation in GPland

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  • HSL come across well; what will not work is when you do not use the wc and XXXX in your own back yard.
    So look at todays national headlines please. The Junior doctors are equally exploited in GP land as well as Hospitals. Its an unpleasant truth. This is not aimed at our lovely leaders in BMA, RCGP who ere sincere in their support the junior doctors
    So I disagree wuith RCGP to extend the training when the ST's go to the mini specialist clinics eg ENT,Opthalmol, Dermatol already and bring back upto date knowledge to our small insignificant practice; that way, we don't particularly need to attend updates.
    The RCGP may not be aware of the above,the quiet good work that (some of) its own members manage to do.
    Is there a lost connection between the RCGP and BMA, LMC . GPC. Its confusing for new Doctors as to what are the different functions of these groups..

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