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Independents' Day

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)

  • Direct Democracy: An Agenda For A New Model Party
    Co-author J. Hunt?

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  • Have to agree with Pete Deveson 110%. One thing I would like to add is that I disagree that we should handle our leaders of the future with kid gloves. This doesn't help them sharpen their skills. We have members of the armed forces dodging or catching bullets and making decisions in much tougher circumstances than ourselves at a much younger age than our own trainees, and they stand to loose limbs and lives, all we endure is a bit of a bruised ego. If our leaders can't cope with a bit of criticism / difference of opinion they really are in the wrong job. They should be old enough by now to take the blows, they are not children but already professionals. I suspect the problem with our leaders of the future is that they are cast from the read-repeat-reward system, our system/RCGP does not take kindly to those who challenge it (Observe HSL comments on anonymous contributors). Abraham Lincoln - "our critics are our friends they show us our weaknesses".... our leaders cannot afford to be so delicate that they cannot handle it this way....

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  • It seems like your article has attracted a lot of antibodies Nishma! I a fellow GP trainee too and doing one of the fellowship programmes.

    I'd like to offer you my viewpoint. I hope you appreciate I'm a bit of an outsider compared to the other commentators; I've spent in total 8 months in GP land 4 as a Foundation trainee and 4 in ST1. I don't think I represent the 'groupthink' cynical GP mentality.

    It is already quite clear to me General Practice has been burdened under increasing pressure. Us trainees are not immune to this. I'm sure you will appreciate the intricacies of the hoop-jumping e-portfolio (is there any evidence-base this improves training?) and the CSA exam (which is likely to unfairly discriminate against non-whites and males).

    Is there light at the end of the training tunnel? It doesn't seem like it given the general mood of all levels of grass-roots GPs I've experienced.

    From all the many things which I've heard, I believe the underlying frustration within the GP profession is with 1) The current state of GP 2) More importantly, the direction of travel.

    Our 'leaders' are telling us everything is okay, when it is obviously not. There is a shitstorm of factors contributing to this: Funding not increasing with patient demand, CQC, GMC, streamlining, efficiency savings and Indemnity to name a few. There's a German word 'Verschlimmbesserung' which basically means an attempted improvement that makes things worse than they already were. GPs are fed up with the poorly thought out 'improvements' which essentially making things worse both by the disruption of change and the long term. For example, I believe the move towards large scale groupings is decreasing doctor-patient satisfaction and increasing stress by destroying the relationship a patient has with 'their doctor'(See the InnovAiT podcast 21 for further info).

    Leaders don't need to be representative, but they do require a follower-ship. The growing frustration/alienation of grass roots GPs needs to be acknowledged and the causes dealt with by our leaders. See Jeeves articles recently- I agree the main priority needs to be urgent funding to the core GMS. The sarcasm, critical comments and cynicism will continue to grow if those in leadership positions put their hands in their ears and whilst the people are crying out for real leaders. The crying will eventually stop- but that's because there's no one left cause they've retired or left the country!

    I hope this feedback serves as a reminder that sometimes we have to self-reflect on our beliefs if the evidence and everyone is telling you otherwise. Good luck!

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  • Ebrahim Mulla | Doctor in Training

    Well said

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  • meanwhile back on planet earth...

    (apropos the article)

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  • Ebrahim Mulla- spoken like a true leader.

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  • Interesting insight Nishma but I wonder did you ever get close enough to Jezza to know his thoughts. There may not be a conspiracy but GPs have been lied to, contracts have been changed, bars set higher and funding is not keeping with demands and complaints are encouraged, regulations are increased. These are facts. No wonder people want to leave. The system is broken and it is time to recognise this. Free at the point of use leads to abuse and unlimited demands. As to comments on why some are anonymous, it is because we do not trust the quangos.

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