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GPs buried under trusts' workload dump

The real conspiracy of NHS England

Dr Nishma Manek

That got your attention, didn’t it? Perhaps a story has crystallised in your mind already.

We all knew it. The government and NHS England have been plotting to systematically destroy general practice. With sympathetic nods and public-facing pledges to try harder, they’ve been taking back our contracts – only to throw them in the fire when our backs are turned, gleefully stroking beards as they watch plumes of smoke erupt from their ivory towers.

It’s a seductive story isn’t it?

But it’s fake news. As a trainee and avid follower of the headlines, I shared these concerns. But I’ve spent the last year as a clinical fellow in NHS England, and I’ve been searching for some hint of conspiracy to destroy general practice.

I expect to get a kicking for this, but I want to lay out some truths. As is often the case, the truth makes for far less juicy reading, so do feel free to switch to Trump’s Twitter feed.

You see, I’ve dispelled some myths of my own this year. I’ve found no hidden agenda to destroy the partnership model. There’s no secret plan to sell us off as salaried slaves to super-partnerships, or knock us down so hungry hospitals can devour us whole. They’re not lying through disingenuous teeth when they say, ‘if general practice fails, the NHS fails’.

They don’t always get it right. They know that a glossy plan won’t matter if it’s not felt in our consulting rooms. But far from being soulless zombies working at the whim of politicians, I can now see they’ve got some of the toughest gigs in the profession.

They don’t have the ability to take to the airwaves, point fingers, and rally the troops with cries for more resources. Or the everyday ‘thank you’s from patients that help us to persevere when tasked with the impossible. And any positive progress or deflected problems often slip under the radar.

But having internalised the same passion we have for shoring up general practice, they toil on. They walk tight ropes in a way that I couldn’t have imagined. And knowing that we’ll never feel like it’s happening fast enough, or going far enough, to keep ahead of rising demand.

Pulling back the curtain, I can now appreciate the delicacy and complexity of the constraints they work within. We’re living through unprecedented political instability, with no ‘magic money’ tree to shake, huge pressures on primary care, and plummeting professional morale. So those sweet spots of where change needs to happen, that seem so glaringly obvious from the outside, are smaller than we might think.

But if you look at the headlines, you’d struggle to believe there’s anything positive happening at all.

Across the world, fake news is having a moment. It feels like we’re increasingly prioritising the deceptively simple over the honestly complex, the visceral over the rational, and making judgements based on summaries of summaries.

Our declining deference to experts, rising scorn for the political establishment, and tendency to lock ourselves in social media echo chambers where opinions are confirmed with breath-taking confidence, rather than challenged, are increasingly blurring the lines between fact and fiction. And the less attention we pay to facts, the more ‘non-facts’ are being deployed.

I’m beginning to worry that general practice is heading down the same path. Doctors are often discerning when it comes to assessing evidence. We remember those lovely funnel plots from medical school, and we’re quick to spot publication bias. But do we apply the same diligent consideration to the headlines in general practice?

Chronic, unfocussed criticism, generalised and amplified in echo chambers, is harmful. And I think we’re at risk of tipping the balance. There’s a sense that it’s now being embedded in the psyche of the profession, spilling over to our trainees, and subtly altering perceptions of our career, at a time when we need them more than ever before.

Criticism is like our body’s inflammatory response to injury. When it’s acute and targeted, it’s helpful. It signals where the insult is so a response can be deployed. But when that inflammation becomes chronic and self-perpetuating, it can cause lasting damage- and damage that continues long after the original insult has been dealt with.

I think this matters. Because there’s a fine line between passionately defending our profession, and inadvertently being part of the problem. And there are consequences of crossing that line. At best, nothing changes, and we’ll continue to wallow in our collective sea of cynicism. But at worse, we drown in a spiral of negativity and, worst of all, deny others the privilege of joining our field in the process.

And those repercussions will continue long after today’s headlines wrap tomorrow’s fish and chips.

Dr Nishma Manek is a GP trainee in London and is the national medical director’s clinical fellow at NHS England

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Readers' comments (57)

  • Oh I thought it was something to do with 10+ years of sub inflation rises in funding for primary care increased dumping of work onto an underfunded and understaffed primary care workforce, the ageing demographics of a workforce/country, increased unrealistic demands.and increasing costs.Wait till the tsunami of indemnity fees starts to hit in the Autumn (another effective pay cut].If they are not plotting it must be just plain ignorance or incompetence.

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  • I'm sorry Nishma. It doesn't wash. Neglect can be just as much abuse as overt violence is.
    'If GP fails the NHS fails'
    Thats what they want isn't it?

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  • I thought this was a well argued and important article. Just wanted to say so, in case I'm the only one posting a positive comment!

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  • You are wrong. Conspiracy theories aren't in fact that glamorous. There is no guy sitting in a bunker in a jump suit stroking a cat, rather it's the banal business of people protecting their own interests. Remember, Jeremy Hunt wrote a book on how to privatize the NHS. I've heard it from reliable sources that government don't want to contract with units smaller than 50,000 patients which is why we are being herded together. We have a college that has only recently stool up for GPs, having spent the last decade toadying up to government and creating the worst exam in medicines history. There are also a few people in the CCGs and PCCCs who have a really low opinion of GPS and want to see the back of us because we hold them to account. A large number of politicians have financial interests in provider companies who are working out where there is money to be taken from the NHS - it's in the public domain and not fake news. Combine that with our death by 1000 cuts funding, a growing army of well remunerated regulators and greedy legal firms that have successfully pushed our indemnity to £10 000 and you can see that this is reality, a boring conspiracy but just as awful.

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  • NHSE and the government are lying, if only to themselves.

    The true lie is that communism and central control can work as a mechanism to allocate resources, when this was disproved with famine and totalitarianism in the 20th century.

    There is always a cost and opportunity cost to all actions. Keeping patients tied to NHS GP, by ensuring that is the only route to NHS services they are eligible for through tax, crowds out private primary care.

    If those in power valued the 'truth' they would acknowledge that there needs to be payment by users of healthcare at the point of use, and that the NHS scores poorly compared to many European systems on outcomes such as dying from severe disease (OEDCD reports) and only does well on outcomes that measure how much a health system is like the NHS! (i.e. Commonwealth report).

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  • Haha.

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  • 1. You are marginal to the real conversations in the cabinet office and DOH.
    2. Unfortunately so is Arvind.
    3. Perhaps not conspiracy, but a clear ambivalence as to whether we continue to do an impossible job on meagre resources (which is fine to them) or collapse and be replaced by a command control system like hospitals (which would also be fine to them).
    4. They say fine words publicly and privately to NHSE to keep everyone quiet whilst this plays out either way. You can tell people's true intentions by where they invest the money. They must find Robert Varnam running round with his 10 high impact actions, and the RCGP staking their reputation on the illusory £2.4 billion quite hilarious.
    5. GPs who work for NHSE and anticipate a parallel career have taken Jeremy Hunt's shilling and have a need to toe the party line (for personal advancement) and buy into it (so they can sleep at night). Your article should have really started with a clear statement of your role and ambitions. Then we would have understood from the first line what your context was: 'ambitious trainee with little real world experience who has plum NHSE job says NHSE doing a great job'. I wouldn't have read any further.
    6. The real test of CO/DOH/NHSEs attitude to general practice is the state of the profession. The only way you can really tell that isn't by working in the NHS directorate, its by seeing patients in general practice, and trying to deliver general practice to a population you are committed to.

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  • There are probably well meaning people in NHSE, you may well be one of them. You haven't specified any of the positive actions that have been taken, and in terms of assessing the evidence, when I started as a partner I left work at 18.30, indemnity was way less than it is now, there was healthy competition for Partnerships, training places over subscribed, sveeral less layers of regulation and the profession seemed stable and well respected. Compare to now, 12 hours days, usuall in at weekend to catch up, not a hope in hell of recruiting, training places unfilled, CQC et al making an almost impossible job that much worse, sppiralling indemnity and anyone who can get out planning to do so. I don't know the motivations, but the results speak columes. It's either deliberate (NHSE or DOH, lines increasingly blurred), or incompetance. End result is the same though.

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  • I have some legitimate and robust questions...if you please....

    What "qualifications" do you need to have to work for NHS England that we do not have?? Please list them...I am asking for specific lists

    What "expertise" do you have or need that the rest of us lack?? A PhD in NHS England studies? We need further clarification?

    To gain authority, you need to explain precisely why you know more than the rest of us that gives you the relevant expertise and qualifies you for this assumed mentorship role to your colleagues?

    We all fully accept that this is your version of reality but it is in my opinion disrespectful and offensive to your colleagues to assume we are all simpletons unable to process any information ourselves without relying on your pre-digested views.

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  • Another non GP telling people who have been doing this job since before they were born how it is! Great. Thank you for the insight.

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  • Nhsfatcat

    If there is no conspiracy then NHSE are like a chef who can burn boiled eggs.

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  • If this post was designed to help us "see the light" then it has had the reverse effect on me.
    Personally, I am bloody sick to death of being "told what to think and do" by those with grandiose and inflated egos. As far as I am concerned intelligent professionals should be "allowed" to come to their own conclusions rather than fed others views-so thanks but no thanks.

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  • The facts on the ground do not reflect the views shared in this article.
    Always the blame lying with the old mantra of increase in population. It's bollocks. That is a small part of it but the constant pace of change; money Diverted away from core / basic services into Revalidation; new teams and non evidenced half ideas and no one seemingly just stopping to learn lessons from failed debarcles ( various IT programmes). No one listening or believing the experts. That's the real problem.

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  • I have a friend who has worked several levels higher than yourself in NHSE for many years, they categorically define that there has been a conspiracy by the treasury to defund and impoverish general practice since 2005, this is completely intentional with no thought to the consequences for the NHS, despite warnings from NHSE - and not something that NHSE has been able to alter, the same individual states categorically "We know general practice and the partnership model is dying, its not that we are letting it happen, we're just not saving it".
    I trust this individual to be honest with me as I've known them for years and they have nothing to gain from this disclosure.
    So if NHSE are standing by and watching general practice die, they are guilty of neglect, and if they publicly have accepted the treasury stance on gp income and resource, they are guilty of colluding in the demise of a profession, and possibly ultimately the NHS.

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  • This comment has been removed by the moderator

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  • The background:-

    https://www.fmlm.ac.uk/programme-services/individual-support/national-medical-directors-clinical-fellow-scheme

    https://www.fmlm.ac.uk/nishma-manek

    I wonder if you are media and politically savvy, using what you describe to attract our attention in one of the means of communication to Primary Care which in my career experience consistently provides a fuel to negativity.

    Typically, exploring the background to the headline reveals a different story, just like here.

    The other comments here also reveal the effect of NHS behaviours on how those at the front line of Primary Care now feel. Surely cause for grave concern?

    I am passionate about Primary Care and have been through my career (nearly at an end - thank goodness you say!) and have recently found the TED talk "Start with Why" followed by the unabridged audiobook an enormous help with the feelings of negativity which you describe. It may help others.

    I respect your right to have an opinion, but wonder if you are exploring the realities in Primary Care which are producing the loss of morale, inability to recruit, some of the negative behaviours becoming more prevalent (or exposed by the pressures) - and before those who wish to comment say "we do not have a problem" - look ahead to a possible situation of clinicians not there due to retirement, illness, etc.

    Happy to explore this further.

    IntraHealth Parkgate Surgery

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  • Azeem Majeed

    Thank you for your article Nishma. I notice that many of the people who have criticised you are unwilling to give their real names.

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  • Tom Caldwell

    No problem giving my real name. You are of course right that there is no conspiracy. It is simply open Tory policy and opportunism.

    There is no way that chopping pensions, reducing budgets and staffing, clustering into nice convenient sized chunks and aligning IT systems to mine information usable by private providers could in anyway be preparing general practice for larger providers to swoop in with APMS contracts.

    There is no way that the NHS is becoming simply a brand under which large private providers are picking off what they see as the juicy profitable bits.

    There is no way for example that these larger groupings could ever be changed to a cheaper to provide GP lead not delivered service... oh no. Nothing in the direction of travel suggests this at all.

    As to how much access I have to insider info, probably a little bit less than you. As to how much you have, only you can answer that.

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  • Sorry Nishma, I'm with DT.
    Some would politely say that 'there are none so blind as those that cannot see', others might suggest 'what else would you expect from someone who has clearly invested in partisanship'.

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  • Hi Nish. Don't normally head below the line myself, but couldn't let the Prof's straw man about all dissenters being anonymous stand so as someone whose stock-in-trade is whinging about the powers that be, here's my chronic unfocussed two cents.

    Let's be honest, this article never had a hope of hitting the fabled 5 stars, but it already has you drowning in plaudits from what Pev might call the wider Morlock community, so swings and roundabouts eh.

    I do think you make some valid points. Of course the people you work with in NHS England are not evil, just as my appraiser is not evil, my CQC inspector was not (provably) evil, and the U-boat Kapitänleutnant in Das Boot isn't evil. They're all normal people trying to do the best they can in tough jobs. But that doesn't mean that their actions and the system they support have a benign effect on us ordinary working GPs; quite the opposite. (Except the U-boat guy, on whom the jury is still out).

    There's a reason we're in a spiral of negativity. In the ten years since I was a GP trainee like you virtually every aspect of the job has got worse. That ain't fake news, it's just a statement of fact, easily backed up by looking at the stats on GP workload, GP pay, indemnity costs, numbers of applicants for jobs and so on. I'm sorry-not-sorry if my response to this is criticism of the forces I perceive to be worsening the situation, whether through malice or ineptitude. But the idea that my criticism is now a bigger problem than the *actual problem* is just daft, frankly.

    "Why are you retiring/quitting/moving to Australia?"
    "Well, my job is fine. In fact, I couldn't be happier. But I keep reading in the papers that GP is bad so I thought I'd better get out". SAID NO ONE EVER.

    I don't know if NHS England can make the job better. I don't believe they go into work each day to actively try and make it worse. But that's what keeps happening anyway. So here's some targeted inflammation for you; tell your BFFs at NHS England that if they really want to Make General Practice Great Again they should take all the five year forward view money and put it directly into the global sum. Nothing puts bums on seats like cold hard cash.

    In the meantime I will continue to call it as I see it. There is a great British tradition of therapeutic grumbling in times of adversity; it's not chronic inflammation, it's catharsis. And without catharsis you know what you end up being full of.

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