It might feel like getting a voice around the table is the hard part for general practice. It is not. It is just the beginning.

There is a salutary lesson for GP leaders from the experience of the Royal College of Nursing. They had a seat around the table of national pay negotiations for the NHS. Important for nurses, to ensure they are represented. But, under pressure from the government to “sell” the negotiated deal to their members they provided what an independent review described as “inaccurate” information to members, and presented the deal in a way “biased towards acceptance”.

When nurses opened their pay packets in July and found they were much lighter than they had been expecting, they called an emergency general meeting. The Chief Executive resigned, and a vote of no confidence was passed, following which the entire council will stand down.

In system meetings, just as general practice will want the hospital and the acute trust to make changes, so they in turn will want general practice to make changes. How does the federation leader, there to represent general practice as a provider, respond? If he or she is too inflexible, the chances of any system changes being realised are minimal. If too flexible, they could end up the way of the RCN.

The job of the leader is difficult. The real work is outside of the meetings. I have written previously about the importance of establishing a mandate with member practices. But this is not a one off event. Federation leaders need a strong, continuous, two-way flow of communication with their member practices. As situations develop keeping practices informed, listening to feedback, and understanding the mood amongst GPs is critical to being able to make the right decision in the meetings themselves.

It is neither possible nor desirable to go back to practices before each and every individual decision is made. Nothing is more frustrating in system leader meetings than individuals refusing to make any decisions without full Board/practice support. The federation leader must understand their practices well enough to know which decisions they can make and which they cannot.

The trap the RCN seemingly fell into was having agreed to something (even if they felt they had no choice), instead of being honest and transparent with their members they tried to “spin” it to make it more palatable. It didn’t work for them, and it won’t work for general practice.

The trust and support of practices, and the ability to maintain this through periods of changes, is at the heart of the leadership challenge. It requires honesty, transparency, and, probably above all else, a relentless commitment to communication. It requires clarity of purpose – of why general practice is around the table and what it wants to achieve. And it requires strength of character, in particular the ability to make unpopular decisions and to speak out when needed (because caving to pressure from above to agree, as we have seen, is a recipe for disaster).

Like I said at the start, getting a seat round the table means the real work is only just beginning…