The letter I had been waiting for dropped through the letterbox. I had been an “A” student right through school, and my sights were now firmly set on Oxford University. The interviews had been hard to read, but seemed to go ok. I opened the letter. “Thank you for applying to Oxford. After careful consideration it has not been possible to offer you a place”.

I didn’t take it very well. Maybe we are less resilient when we are younger. My (somewhat sulky) response was to decide university wasn’t for me, and I headed off to do voluntary work (“something that mattered!”) instead.

A key part of resilience is described by Bruce Cryer and his colleagues at HeartMath as “releasing the emotional grip” that stress has on us. In their 2003 Harvard Business Review article they describe how to do this, essentially by using techniques to accept the current situation and to develop a new perspective centred on what actions you can take to change the situation.

It took me a long time to do this. After my rejection, I actually did well in my A-Levels, but the following year refused to apply to Oxford again on principle (the principle of, “if they don’t want me, I don’t want them”). I was hanging on to the pain of rejection instead of thinking positively about the future.

Changing our own mindset that things need to and can be different is at the heart of resilience. I think this is the hardest part. In the end, I was sat down by an individual who had become something of a mentor to me. He laid out some different options of what my future might look like. One involved going to Oxford. It did look like the most attractive path… Something seemed to click inside me. It might have taken 18 months(!), but finally I could accept it was me who hadn’t been ready for Oxford (and not vice versa) and I decided to swallow my pride and reapply.

While tenacity and perseverance are key parts of resilience, it is adaptability, and the ability to change mindset, that are more important. Blockbuster Video, Borders Books, Kodak (and many others) kept going for as long as they could when things were tough, but they did not adapt to the new world and the changed environment around them, and ultimately were not able to survive.

I recently had a conversation with Dr Mike Holmes, the newly elected vice chair of the RCGP, about resilience and the importance of it for GPs right now. In echoes of the HBR article, he identified three elements to GP resilience: pragmatic optimism; making do with what you have while making things better; and allowing yourself to think differently.

There are opportunities and new ways of working that can help general practice. Mike Holmes outlined some of these in our conversation. The hard bit for many GPs, as for anyone in a difficult situation, is letting go of the unfairness of what is happening and shifting into the “pragmatic optimism” that Mike describes.

Some GPs and practices have not yet been able to make this shift in mindset. Some will never make it. My life was probably changed forever (with a lot of help!) by shifting my focus from unhappiness with my rejection, to taking action to remedy it. I was accepted into Oxford at the second time of asking. Changing the direction of our lives starts with ourselves, with us releasing the emotional grip our current circumstances have on us, and changing our focus from causes and blame to our response and what we can do about it. This is being resilient.

Well what do you think? Is it? It may well depend who you are. If you are a GP you are unlikely to think so, but as a hospital Chief Executive, who has heard all about the workload and workforce pressures general practice is under, it is easy to draw the alternative conclusion.

But correlation, as my PhD wife constantly reminds me, is not the same as causation. The fact that general practice is struggling with workload pressure at the same time as there is rising demand in A&E only means the two are correlated. It doesn’t necessarily mean one causes the other. And so it is that research was published this week in the British Journal of General Practice looking at the factors affecting emergency department attendance. They found (drum roll),

“…the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.”

In other words, people are living longer with more long term conditions. This in turn is causing the growth in demand, both for GP practices and A&E departments. The more GP consultations a person has, the more likely (for many groups) it is that they will also have more A&E attendances. Growing demand is the causative factor. Pressure on A&E departments and GP practices are simply correlated.

I am on Twitter (@BenXGowland – the X is actually my middle initial, as opposed to denoting membership of some secret society). You should be too. The GP I most enjoy following on Twitter is Dr Steve Kell (@SteveKellGP). He recently ran a survey (now I recognise I need to be careful here as having preached about the difference between correlation and causation, I know I am going to get stung on the validity of a small sample size, but nevertheless) which found that, of the 48(!) GP practices that responded, 81% had not been asked if they were busy or managing in the first week of the New Year, with only 19% saying that they had. Steve’s concern is that “sadly we value what we measure”.

But simply knowing that a problem exists (there is too much demand, and it is getting worse) does not actually help. Nor does finding someone to blame (whether it is GPs blaming hospitals, or vice versa, or the government, or Jeremy Hunt etc etc). The only real option is to work out what we can do about it (because even if there was more money, which there isn’t, there will never be enough).

Which brings me to another interesting exchange on Twitter involving my friend Dr Kell. His practice is a leading light in the Primary Care Home movement, and he announced on Twitter that his practice had achieved a (highly impressive) 5.5% year on year reduction in emergency admissions. Now that prompted a question in response from Professor Harris of Lakeside Health asking,

“where lies the incentive (other than patient benefit) of GPs working harder/differently/more productively if the £ benefits remain with trusts or CCGs?”

The essence of this question is what is the point of the primary care home, of groups of practices working with other agencies, and managing demand in a different way in the way that Dr Kell’s practice has, if there is no financial return for the practice? His response was that while there is no direct financial return, it makes things better for patients, for staff, and is more efficient.

If we think about this in the context of constantly rising demand, the challenge practices face is how to adapt to meet this demand in different ways. Not because there is a direct and immediate financial benefit, but because the current system is not working, and without change the system is likely to collapse. Everyone working in the system has a responsibility to understand and accept the current realities, and to think and act differently as a result, so that things can improve.

General practice is not responsible for the pressures A&E is experiencing, but it is responsible for adapting and finding new ways of dealing with the demand (like the work being undertaken within the primary care home sites) so that general practice, and the NHS, can continue to manage the rising burden of disease. And if you take nothing else away from this, at the very least you should follow @SteveKellGP on twitter…