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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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  • Dr Nishma Manek-JonEnoch June2017 3x2 Duo BLOG

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Readers' comments (57)

  • "The revolution will not be televised" G.Scott-heron

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  • Nishma,I for one can see where you are coming from. Being one of those BMEs what has been battered by four NHSE and PCT louts for 7 years just because I had the impunity to take one of them to an Employment Tribunal and then getting an affirmative for 3 cases against the PCT single-handed while PCT was represented by a respected Law firm from London. I declined to sue them and offered to shake hands but the gesture was not appreciated.
    I considered myself to be going into a spiral of negativity from the point when I actually became a partner as at every step, the PCT Contractor would step on my toes.
    And then I ended up in a course of Clinical Leadership. I went through the modules - The Myers Briggs self assessment, Negotiation skills, the wonderful prospects of our 20th century state of art NHS and blah blah blah.
    For a few months, I was elated and as positive as one can be. The course finished and I was sponsored to do a BME Leadership course. One of the Speakers just happened to be our esteemed CQC Chief and I even felt positive about his work.
    Then I came back to the reality and my Mentor in Manchester wrote to the local NHSECCG Team recommending me to participate in the local development programmes. The balloon burst. I was not welcome.
    You've just been to a course and I guess you are still sailing on that cloud which actually will fizzle away because it is a cloud - it clouds your thinking, your judgement and your perception of reality.
    A course is a course, unfortunately, and brainwashing techniques are far advanced but they do not do any good as they prevent you from even considering the eventuality that there are flaws within the system.
    I repeat myself in forums raising the same stale topics but until somebody explains to me why my payslip/ my Open Exeter statement/ shows 'Total Payment Units' as 4660 but I am being paid for only 3450 - I will not rest.
    In a private company if your payslip said your payment is for 4660 and you were paid for only 3450 - the matter would be in Court.
    In NHS, there is no institution in this country which can explain the discrepancy and no solicitor wants to touch the matter till I get an explanation from somebody.
    Corruption, thy name is NHSE.
    We can't shut our eyes to criminal behaviours just because somebody funded a Leadership course and promised to make us world class leaders.
    Cynicism is at times the first step towards sanity. ( That is my quote and I sincerely believe in it)

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  • winston had been advised to revise the boot production statistics down in back numbers of the times . he knew at heart the second statistic was no more or less a lie than the first as the evidence of his own eyes showed the majority of the population walked around barefoot and in all probability no boots at all had been produced

    (with apologies to George orwell)

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  • There are some fundamental flaws in this article, made worse by the wide readership and the lack of declaration of interest.
    The very fact that NHSE will only support bods of 30k plus patients (fact) will serve to destroy the conventional structure and worse prevent those practices doing anything different or novel. I wish NHSE had a plan but having dealt with them for the Practice Pharmacy pilot it is terrifyingly clear that they have no plan, no vision and unfortunately no insight. The move to STPs will further confuse matters.
    A misguided plan I can understand complete incompetence I can't.

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  • The fundamental problem is the inability of GPs to seriously look for ways of working and earning outside OF the NHS. We choose to be dependent and then whinge about the consequences.

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  • you forget to use the wordlist! please rewrite your articles as requested, sorry, suggested by your mentor:
    brilliant job
    hard working
    real difference
    value for money
    NHS leadership
    forward view
    24/7
    GP worthless scum
    more research is needed
    can i have a tenured research job please?
    (hint - one of these is NOT to be published)

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  • So the leaked memo of allowing vulnerable and failing practices to wither on the vine was not in fact true?

    So all these collapses are not part of a 'National BluePrint'?

    You take us all for fools.

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  • I have been trying to work out why I feel such disquiet at this article when the comments seem at variance with it, and with which I broadly agree.

    In my previous comment I posted background for Dr Nishma Manek.

    "National Medical Director's Clinical Fellow Scheme

    The National Medical Director’s Clinical Fellow Scheme for doctors in training in England is sponsored by Professor Sir Bruce Keogh and managed by FMLM.

    The scheme has been established to fast track and support those doctors in training who present with the clearest potential to develop as medical leaders of the future."

    Perhaps my concern is that the outcome of the time spent in that environment has resulted in an article that to me is confusing and is certainly not inspirational, uplifting or what I would have hoped from "a medical leader of the future"

    No anonymity here, our Teams are constantly discussing ways of maintaining and modernising the services provided by our Practices to our Patients, and am very happy to discuss with anyone from FMLM.

    To do this I am even considering subscribing!

    Andrew Challis

    IntraHealth Parkgate Surgery

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  • This comment has been removed by the moderator

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  • Its not important whether its NHSE trying to hold the fort,cock up or conspiracy as behind them there is little political true will from any party to adequately financially support GP in its present form in common with many public sector good things unless there is a massive problem [Like having adequately resourced
    and monitored decent building and fire safety regulations]

    GP trainees are appropriately savvy consumers and are opting out of traditional career arrangements until things are clearer and fairer.

    The next iteration of general practice will not be what people are used to or what they want, but as its needed it will need to happen and be made attractive enough to encourage enough people to do it.

    These are difficult uncertain times, and we are part of that unfolding uncertain change.

    Luckily, we have great people, with a great NHS, so I think it will be alright in the end.

    But its going to a really difficult next few years.

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