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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)

  • Vinci Ho

    Always enjoy the poignancy of many of your previous articles, Nishma.
    Returning to reality , though , is a different matter.
    At the end of the day , people working in NHSE are merely doing 'a job' earning a living and I agree that they might want to do their best to improve this undeniably extraordinary and unique circumstance in the history of British general practice. But have they really had any autonomy or must they follow orders from above instead? Like us , perhaps they have very little choices .Oppression is descending from the top of hierarchy at successive level. Lack of determination and leadership to fix domestic issues in this government is evident .
    But if one wants to give some benefit of doubt to the politicians, the verdict is still :''Never attribute to malevolence what is merely due to incompetence'' (Arthur C. Clarke).
    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 whisptof '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.

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  • Hi
    Brave article but u have confused the decency of those u have met with a malignant system (whether so by design, incompetence or entropy history will tell eventually)
    The chronic inflammation you identify is the direct result of repeated failure to address many acute flares over many years. The damage is not beimg caused by chromic maladaptive GP criticism but by the cumulative fx of the failures themselves. It is hard to avoid the conclusion that this disruption is intended at some level but more scary is that it is pretty clear that like brexit no one has a proven replacement that is sure to work and so the damage to equitable healthcare in this country could be profound & irrecoverable. And that those social darwinists who profit from it won't be that bothered by what happens at the bottom of the pile

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  • I for one will NEVER forgive the Tories or their minions for what they have done to the NHS.It will take generations to repair the damage that has been done at all levels it hasn't gone too far to be repaired already.Do not be an apologist for what is in effect a branch of government.There is blood on their hands and no amount of excuses will wash the stench of this away.I will Never vote Tory again as long as there is breath in my body.

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  • You mean it's cock-up, not conspiracy?

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  • Dr Dean Eggitt

    Just a thought....

    Groupthink, a term coined by social psychologist Irving Janis (1972), occurs when a group makes faulty decisions because group pressures lead to a deterioration of “mental efficiency, reality testing, and moral judgment”. Groups affected by groupthink ignore alternatives and tend to take irrational actions that dehumanize other groups. A group is especially vulnerable to groupthink when its members are similar in background, when the group is insulated from outside opinions, and when there are no clear rules for decision making.


    Janis has documented eight symptoms of groupthink:

    Illusion of invulnerability –Creates excessive optimism that encourages taking extreme risks.

    Collective rationalization – Members discount warnings and do not reconsider their assumptions.

    Belief in inherent morality – Members believe in the rightness of their cause and therefore ignore the ethical or moral consequences of their decisions.
    Stereotyped views of out-groups – Negative views of “enemy” make effective responses to conflict seem unnecessary.

    Direct pressure on dissenters – Members are under pressure not to express arguments against any of the group’s views.

    Self-censorship – Doubts and deviations from the perceived group consensus are not expressed.
    Illusion of unanimity – The majority view and judgments are assumed to be unanimous.

    Self-appointed ‘mindguards’ – Members protect the group and the leader from information that is problematic or contradictory to the group’s cohesiveness, view, and/or decisions.

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  • 2 articles in pulse now from a similar theme from leadership fellows. Very questionable ideas being purported. Clearly upset us all and an indicator actually of poor leadership. What is going on? I think that there is a major problem with leadership training. How are we as a collective feeding this back? Where are the GP educational supervisors? I would really appreciate their opinion on pulse. Could they be interviewed. Nishma have you discussed your views with your supervisor? I think you should reflect. Thank you for sharing and please do not be hurt by the hostility that you are experiencing. You are a trainee and we should be more respectful.

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  • Increase hoops for GPs and CCGs and government bodies all not listening and ignoring patients who like a good quality local and friendly healing centre with the modern age of medicine. That is the messy culture of our environment .

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  • Nishma have you ever spoken to Simon Stevens? Have you seen his speech to delegates at a conference when he was just leaving his job as CEO of Commissioning at United Health (where is currently being taken to court for part of their fraud) stating that he had a plan to open the NHS to US private health firms? Have you seen what is happening in Plymouth where NHSE closed 4 surgeries despite widespread patient and staff protest and now more surgeries are closing due to excess pressure and lack of GPs?

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  • On second thoughts I'm frankly more dismayed than angry - bemused - is this really REAL - comes across as propoganda - Let's get some fresh faced trainee GP to tell them it's all going to be OK and was just a bad dream! REALLY? That's the best you can come up with? We really are up SH1T creek without a paddle!!

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  • I too deal with NHSE extensively, from a completely different angle and none of the people I deal with know that I was a GP.

    I agree with the vast majority of comments and criticism of the article, the comparison with fake news is a little childish however.

    Although individuals within NHSE may not be evil or have bad intentions there is no excuse for incompetence. The civil service structure rewards project completers and often we have met several NHSE representatives whilst negotiating as the managers move posts so frequently.

    Which is one of the reasons NHSE cannot negotiate competently.

    Don't under estimate the aims of the political policy - there may not be a stated aim of destroying the NHS but for many it is a part of their ideological make up.
    The fact the consequences and cost may be huge is of no consequence to them.

    I suspect the comparison we should be making is to the grenfell tower disaster and the years of choices that led to that event. I was dealing with mini disasters everyday when I quit GP land. It's worse now.

    I hope the writer can reflect as to why they are simply wrong.

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