It is hard not just to be extremely angry with the 24/25 GP contract.  It not only fails to make up for the real terms cuts in funding practices have suffered in recent years, but also introduces further cuts for the year ahead.  Why would the government and NHS England do this?

There must be something deeper at play than a lack of understanding of the pressures general practice is facing.  Even NHS England national director of primary care Dr Amanda Doyle admitted that the contract would “only make a tiny difference to practices”.  So if the problems practices facing are understood, the further underfunding must be a deliberate policy.

I am not a conspiracy theorist, but this really does not make any sense unless there is some form of agenda at play.  What could the reason be?  I do not know, but here are some potential rationales.

1. General practice has fallen down the NHS pecking order. The introduction of Integrated Care Systems marked the end of the purchaser provider split and the end of the pivotal role of general practice in directing NHS resources.  Instead the priority has more explicitly turned to secondary care, and as a result resources are being re-directed in that direction.

2. Funding cuts are required and general practice is a soft target. The NHS is under huge financial pressure, exacerbated by the consultant and junior doctor strikes, with huge overspends across all integrated care systems.  The money has to come from somewhere and general practice never overspends on the budget set for it, and so is one of the few places that real savings can be made.

3. The government believe GP partners are fat-cats. You do get the sense sometimes that, despite everything general practice went through during the pandemic, at a national level there is a lingering belief that GP partners milked the system and did very well financially thank you.  They also seem to think that any investment into general practice simply ends up in practice profits and does not find its way through to patient care (hence all the additionality bureaucracy around ARRS roles).  So continually reducing the funding for practices is a way of redressing the balance.

4. General practice cannot do anything about the cuts. Whilst consultants and junior doctors can strike, it is very difficult for GPs to take similar direct action.  Even the GPC are saying that they are not proposing contractual action and instead are looking at a range of non-compliance measures that look like they will be difficult to enact and relatively easy for the government to endure.  This impotence is understood, and makes targeting general practice relatively pain-free for the system.

5. There is a deliberate strategy to undermine the partnership model. If the only constraint on the government negotiators was the funding envelope, and they were committed to the ongoing sustainability of the partnership model, the funding tied up in PCNs (and in particular the additional roles) could have been freed up for practices.  Funding for GPs and practice nurses could have been included and the ring-fencing of these already existing funds could have been relaxed, so that the benefits for practices would be much more tangible.  This would have been cost neutral for the government but they decided not to do it, which suggests that there is no desire at a national level to keep the model sustainable.

There has been a lot of talk about the future of the partnership model, but the government cannot afford to buy partners out of their contracts.  Instead, they can make the existing contract so financially unattractive that partners are left with no choice but to move to any new arrangement that is proposed.

6. The government want to soften up general practice for bigger changes next year. PCNs were accepted five years ago by general practice as a necessary evil in return for securing the additional funding that came with them.  Similarly, by creating a situation whereby general practice has been starved of funds for three years the government will be in a much stronger position next year to make major change a requirement of any additional investment, with the profession then in no position to refuse.

The truth is I don’t know why the government have decided to impose such an inadequate contract this year, but there must be elements of at least some of these reasons behind the decision.  Getting underneath it and calling it out is something national GP leaders need to prioritise, because if general practice wants to be successful in any action it takes it needs to know what it is up against.