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Gold, incentives and meh

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)

  • I'm not sure if I'm intellectually challenged, but I just don't understand this article?

    Who is the "they" you keep referring to? Is it GPs working within NHSE? Is it managers? Is it the government?

    As a frontline GP working in deprivation, I am utterly perplexed by your viewpoint.

    Am I wrong to assume that NHSE represents the government? Are you seriously defending this government's track record?

    The 2012 HSCA was an unmitigated disaster and has accelerated the road to privatisation. The ICS is the thorn in the side of this privatisation agenda - which is why it has been slowly and painfully eroded over the last 5 years.

    GPs don't really change - we've always valued autonomy, continuity and the ability to innovate. These are the cornerstones of partnership. But terms and conditions have been made so unpalatable that we are all turning our back on it.

    Who do you think is responsible for these terrible T&Cs? It's certainly not Trump.

    Please could you explain why NHSE moved practices down to the lowest common denominator within the PMS reviews and why they are doing nothing to protect leaseholders within health centre buildings and why they are not intervening in rising indemnity costs?

    And please explain who the "they" are.

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  • Oh my god I cannot believe I've just written 400 words for Pulse and not been paid for it.

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  • Having been in a position to "negotiate" with NHS England over GP contracts I am fully aware of the pressures they are under and sympathise with the difficulties they face which are part of the Tory Policy to destabilise and privatise the NHS (sorry 'tis sad but true). I will not accept however that the negativity and demoralisation of the GP's at the coal face is contributing to the problem. I for one have reached my limit in being expected to do more, be responsible for more and do it with ever diminishing finances and to do it with a smile on my face in order to attract unsuspecting trainees into the mess. I am sorry Nishma, but your comments are well meaning but unfortunately both insulating to those experienced practicing GP's and incredibly naive. It would be interesting to hear your views in 5 years.....

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  • NHSE are just obeying orders and do there jobs. I've heard that before somewhere.Ah yes.This is the explanation given for some of the most nasty things done by the human race,to the planet and other Humans.I was just doing my job, it doesn't make it right though.

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  • I was naive when I was young too and believed DOH was doing its best. However I am older now and I think you will find that these conspiracy theories you mention about a secret agenda to destroy general practice to pave the way for private companies are absolutely 100% true !!

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  • I'm not sure I understand your argument. You tell us that we shouldn't discuss the negative aspects of our profession (of which there are many) but then dont provide us with any alternative argument to suggest why we shouldn't!? We have reached a tipping point and it's high time we all started sharing the success stories provided by the desperately needed GPFV...oh wait...

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  • Tom Caldwell

    Hold on hold on, I get it... Its satire isn't it?

    This is tongue in cheek

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  • This comment has been moderated

  • so basically you're saying it's cock-up not conspiracy

    could be either but the effect will be the same

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  • Riddle me this....

    Why is it that NHSE refuse to let struggling practices close their lists to give them a chance of survival but as soon as they collapse and the remaining partners have to hand back their contract NHSE take them over and immediately close the practice list.

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  • Just some numbers, not opinions. In NI
    [2004] Average profit per patient per year =£ 80. Consultation rate = 2.5/ year.
    [ 2015 ] Average profit = £ 60. Consultation rate = 6 / year.
    or 80/2.5 = £ 32 vs 60/6 = £ 10.

    No hidden agendas. It is open warfare and we are the sitting ducks. Hunt called it Penance, I think.

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