One question that is largely ignored in the debate as to whether the independent contractor model has run its course for general practice is what the impact of its existence is on the totality of GP resources.  Does the model increase or decrease how much funding goes into the service?

This is a different question from that of whether sufficient resources are being invested into core general practice.  Overall underfunding aside, the question for today is whether the total amount invested would be more likely to go up or down if we were to move away from the independent contractor model.

At present there is national contract for general practice that is agreed with the BMA and the funding at a national level is then ringfenced.  Local areas can introduce local enhanced service contracts that are in addition to the national funding that has been agreed.  For the last two years there has been no negotiated agreement between the BMA and NHS England, but instead the agreement reached in 2019 has stood, and so there remains a ringfenced fund for the service.

Without the independent contractor model this national ringfencing of resources for general practice would be lost.  The funding instead would be transferred to local ICS areas, who would then in turn decide how much of that funding to pass on to general practice.  Or, the funding would go to the host organisation of local general practice, and they in turn would decide how much to pass on to the local practices.

Of course, in both these scenarios the amount passed on to general practice could be greater than the nationally identified total.  The ICS and local plans for a shift of resources from the acutes into primary and community care could result in an even greater investment in general practice, and should such a change occur I am sure promises of this ilk would be made.

However, it has long been a complaint of the system that when system savings have to be made (remember there is now a system financial control total that has to be delivered, rather than ones for individual organisations) that general practice has been exempt from taking “its share of the pain”, because of the way its national funding is protected.  Once this is removed it seems highly likely that cuts to general practice funding would form part of local financial recovery plans, given the system financial pressures that exist.

We have seen this scenario play out with community services many times over the years.  Originally acute and community services were in unified organisations, but were separated in many places when NHS trusts came into being because the resources intended for community services were being sucked in by the hospital services.  Even now as they start to come back together we are yet to see any big new investments into community services, and doubtless that wheel will have to turn again.

While the totality of the investment into general practice through the national contract is clearly lacking, the argument that this investment will be increased with a shift to a model of funding via the local NHS does not hold water.  The ringfencing would be lost, and the system pressure to use the funding elsewhere would be hard to resist.

If the independent contractor model was abandoned individual practices would no longer have the pressure to sustain themselves as organisations.  However, that pressure would still exist up the line at the level of a bigger and more distant organisation, and the most likely result would be a stripping of resources from local practices to meet a corporate cost pressure elsewhere.