Ben Gowland introduces an exciting new series from Ockham Healthcare:

“In the last couple of years I have written a few articles about the independence of general practice.  The current review of the partnership model being carried out at the behest of government, which is considering what has been the bedrock of general practice for so many years, will inevitably have to consider the issue of independence.  This prompted me to bring together and update what I have produced so far, along with some new thoughts, to create an autumn series of articles on this topic.  Over the course of 5 articles throughout August I will consider the threats to the independence of general practice (from within general practice, from the wider system, and from the review itself), reflect on its importance, and identify what might be needed for it to be preserved.”

In this first blog Ben considers the impact that fewer and fewer GPs choosing to become partners will have on the independence of general practice:

Without GP Partners General Practice will lose its Independence

For me, one of the biggest strengths of general practice is its independence. It contracts with the NHS, but is not part of the monolithic NHS structure. For some this may feel like a technical difference (after all GP practices can still access the NHS pension, and they are funded with taxpayer money) but for someone who has spent 20 years working in the NHS like myself the difference feels much more fundamental.

GP practices are bound by the terms of their contract with the NHS. But within the boundaries of those terms they are free to innovate, make changes, and take whatever decisions they want to improve care for their patients and the working lives of their staff. This is in stark contrast to NHS organisations that are bound by NHS-wide restrictions, ways of operating and approval mechanisms that often stifle innovation and directly impact on culture.

It is now widely accepted that GP practices require more money – whether they are funded directly or through a contract. Moving away from the independent contractor model is not an answer in itself to the challenges facing practices. It will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Independence is not a cause of these problems, but rather is the only reason GP practices have been able to continue the way they have despite the current pressures.

Yet, sadly, the independent contractor model is teetering on a knife’s edge. I visited a practice recently that a year ago was a relatively stable, well-run, 4 partner and 7500 population practice. Within the space of two weeks two of the partners resigned. One was retiring, and one was emigrating to Australia. A few weeks later a third declared they were also resigning as they wanted to become salaried. This left a single GP, who had neither the skills nor the desire to be the sole partner of the practice. She wrote to the CCG informing them of the situation and declared that if a solution was not found she would be forced to hand back the list.

This scenario and others like it are being played out throughout the country. The inability to recruit GP partners is rising to the top of the challenges facing GP practices today. Every resignation of a GP partner creates panic within practices, a sense of being trapped, and a fear of being the one left carrying the costs of closure.

The recent push to secure 5000 new GPs, whilst unlikely to be achieved, has brought new GPs into the profession. But many of these GPs are choosing part time or portfolio careers. The competition for new GPs is pushing up the pay for salaried GPs. The new extended access and A&E based services provide well-paid, flexible alternatives for new GPs, further increasing the challenges of recruitment for practices.

The risk is that, unconsciously, we are creating a system that rewards salaried GPs and punishes GP partners. The number of “zombie practices”, where the salaried GPs earn more than the partners, is reportedly on the rise. By not intervening, general practice as a profession is risking its independence. Without GP partners, there are no businesses that can deliver against the contracts, no practices as we know them today. The NHS will have to directly deliver the service. Once independence is gone, it will never be regained.

I do not believe GPs, even new GPs, by not choosing to be partners are choosing for general practice to relinquish its independent. But I believe that is exactly what is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

Nigel Watson is leading a review of the GP partnership model. My sense is we need to make becoming a GP partner more attractive. We must provide more training and preparation for GPs who do want to take up the challenge of becoming a partner. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. With or without the review, unless we take action now, general practice will lose its independence.

The world has changed for general practice. A new, more challenging external environment means the behaviours that have been successful in the past no longer work. A new paradigm is required. New behaviours are needed for general practice to thrive in the new environment.

Who is to blame for the current crisis in general practice? NHS England? The government? Jeremy Hunt? Workforce planners? The bankers because of what happened in 2008? Millennials, because of their demand for instant-everything? Somebody else?

Whose job is it to sort out the crisis that general practice is in? Is it the same people whose fault the crisis is in the first place? Or is it Simon Stevens, NHS England, Jeremy Hunt, the government, or maybe even the BMA and the national general practice organisations?

These will not be unfamiliar questions for GPs. The injustice of the current situation pushes them into almost constant consideration. But focussing on them does not help individual GPs and practices find a way through the challenges they have to contend with on a day to day basis.

I am sure many readers will have at some point come across Stephen Covey’s book, “The Seven Habits of Highly Effective People”, first published in 1989 with over 25 million copies sold. Within the very first habit that Covey identifies of very successful people (“be proactive”), he introduces the Circle of Concern and the Circle of Influence.

The Circle of Concern contains all those things we focus our energy and efforts on over which we have little or no control, such as the weather, Iran’s nuclear programme, or national debt. For GPs it includes working out who to blame for the crisis afflicting the profession, and considering how much of the soon to be announced additional NHS funding will make it to front line general practice.

The Circle of Influence contains all of those things that we can directly control or influence, such as our actions, our behaviours, our family and our colleagues. For GPs this includes their own individual practice.

The habit successful people have, according to Covey, is focussing their energy and effort in the Circle of Influence where they can make a difference, and not wasting it in the Circle of Concern over which they have little or no influence.

I see this difference regularly in GP practices. The factors causing the crisis are outside of the control of practices. The local response to them, however, is within their control. Some GPs and practices focus their energy on the former, and some on the latter.

The barrier that stops many GPs focussing on the Circle of Influence and the changes they can make is this question of who is to blame for the challenges the practice faces, and whose job it is to sort it out. If it is not my fault, and I am essentially a victim of a system failure, why should I be the one who has to sort it out? Letting go of the unfairness of the situation is far easier said than done.

But the practices who are thriving and doing best in the current environment are those focusing their energy within their Circle of Influence; the ones who are looking at how their own behaviours and actions and relationships can influence and change the current situation for the better. They have not waited to react to changes that others will make at a national or policy level, but have taken things into their own hands.

I recently visited Thistlemoor Medical Centre in Peterborough. The majority of their local population do not have English as a first language, and recruiting GPs has been a longstanding problem. But they have focussed on what they can control, and have created a really innovative model so that instead of relying on Language Line they have trained HCAs recruited from the local community to both interpret and take work off the GPs (you can find out more about their model in an upcoming episode of the General Practice Podcast). The practice is thriving and continues to grow at well over 1,000 patients a year.

In Plymouth three practices merged in 2014 to form Beacon Medical Group, and they created a new multidisciplinary team to manage the on-the-day demand. Since then, in the midst of a really challenging local environment, the practice has grown and continued to prosper.

These are just a couple of examples, and there are many across the country. What they have in common is that local GPs focussed on what they could control not what they could not, and took action. They did not waste their energy assigning blame or hoping for national solutions, but instead channelled their efforts within their own Circle of Influence to change the direction in which they were heading.

Thinking about who is to blame for the crisis in general practice is considering the wrong question. It is operating in the wrong circle. The real question to consider is what can I do, what can I influence, to create a vibrant and positive future for my practice, and to focus all my energy and efforts there.

The following Blog was previously published by Sarah in a series of tweets (@smizz) and is published here with her kind permission. Thanks Sarah!

Ah, my GP is flipping amazing. I can’t explain how good it really is to have someone who knows you & your medical conditions & what matters – someone who just, like, knows this without ever looking back at the records. Someone who sees a longer & bigger picture.

Sometimes we have disagreements on what the longer picture looks like. In the beginning we’d argue. But he was the only GP at the time who decided to take responsibility for me. Most let me jump from GP to GP. But after every test he’d say, “you do this & you come back to me”

I didn’t know at the time the benefits of having continuous care. I was young & impatient. But now I really get it. Today he instantly knew I had an infection (cuz he knows what my normal is), he prescribed me more stuff cuz of a previous diagnosis to help with current sickness

I whined about my leg being numb esp when I run around 5K & how I wanna run half a marathon & I can’t get past 10K (which is still a HUGE mile marker for me). I said all of my friends can run a (half) marathon & I can’t! & he was like:

“Not all of your friends Sarah. I can’t run a half marathon & I’m your friend.” It sounds proper Cheesy to write but also it felt really genuine.

He asked me about PhD work, what Prague & Japan was like. He told me about a beautiful Japanese animation he watched the other night on Amazon Prime. Even Googled it. I gave him Japanese weird tasting Kit-Kats & he seemed pretty made-up by my gesture.

Then I went on my way, not before he gave me his wise-words full of living life & selfcare wisdom as I went to leave. Dude has his moments as a proper philosophical guru. Then of course, he made sure – as per – that I come back to him to check-in in a few weeks.

GP’s will NEVER be replaced esp by apps. And we need to make sure we take care of them, as they take care of us because they’re the backbone of the NHS and the community. And my GP turns out to also hold me up when I feel like I’m falling down. I know they do this for everyone.

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…

Here at Ockham Healthcare, the question we have been giving most thought to is what the future of general practice will be.

We asked Mark Newbold what he thought the biggest change to general practice would in the next 10 years. Find out what he said here. We will be asking the same question to a whole range of people over the next 6 months, in an attempt to build a picture from a variety of perspectives as to what the future will hold.

We also want to ask you the question. We want you to be part of the debate. We want to know what you think the future of general practice will look like in 10 years’ time. Do you think independent general practice will still exist? If not, what do you think will be in its place? Will the role of the GP have changed, and if so what will they be doing? Will technology have transformed the way patients and GPs interact? Will the registered list even still exist on a local basis? Will we have moved all the way to 10 or 20 large providers of general practice? Or will the profession have been subsumed within acute hospitals, community trusts and the nascent accountable care organisations? Or will it be exactly the same as it is now?

These are important questions. Each practice is regularly faced with decisions about its future. GPs have to determine how much autonomy to give up to federations and networks, and how much to retain for themselves. Commissioners have to choose how to invest the GP Forward View money in general practice for best effect. Everyone has to work out how to cope with the falling numbers of GPs.

A clear vision of the future will help. At present, there isn’t one. If general practice knows where it is going, it is more likely to be able to control its own destiny, to make the right decisions today that will impact tomorrow, and to build for the future instead of protecting the past.

Be part of the conversation. Tell us what you think. We literally want to hear your voice. You can do this in a number of different ways. Either record your views on your phone or ipad or computer, and send the MP3 file to me, Ben Gowland, at ben@ockham.healthcare, or we can set up a 5 min Skype call where we can record what you think, or just email me and we will work out a way to do it!

We will be bringing all of the different thoughts and thinking together at our conference in March next year. Get involved now, so that we can shape the future together!

We all have questions about the future of general practice. In his latest blog Ben discusses some of these key conundrums and introduces an exciting opportunity where you could be involved in developing some of the answers…

What is the future of general practice? What will it look like? Will we still have local GP practices? Will GPs continue to do what they are doing now? These are big questions, and probably ones we don’t spend enough time thinking through.

For most of us, general practice has always been there. It is one of only two fixed points of our health service (along with hospitals). I have met many GPs who describe themselves as being on a ship that is sinking, and they can’t see any way that disaster can be averted (other than a serious investment of funding, which seems unlikely in this economic environment and with this government). They urge each other to get off the ship (Australia, retirement, locum), and as a result the number of GPs is falling, despite best efforts to increase it by 5000.

The fixed nature of the GP practice means it can be hard to envisage a new future for the service. I have previously argued that general practice requires more than incremental change at the individual practice level, and that a more radical transformation is needed. But what will the nature of this transformation be? We know what we need to change from, but what we need to change into is less clear.

There are different views about the future. I have met some who are 100% certain that scale is the answer to general practice. They talk about it as being self-evident (which isn’t an argument), and say it with such conviction that many go along with them without careful questioning. I have talked about the potential benefits of operating at scale (essentially: lower costs; higher income; ability to manage demand; and readiness for the future), but have always been clear that these benefits are not automatic, and that they only come by making the changes not possible at a smaller scale.

If big really is the answer, then how big? Here we do have a divergence of answers. The primary care home model is clear that populations of 30-50,000 are what is needed. But on the other hand, Mark Newbold, Managing Partner of super practice Our Health Partnership, recently told me that the full benefits of scale required a population of over 400,000. Now, those two models are looking at two different things – the former is about redesigning local care, and the latter about reducing costs (broadly) – but just the diversity of answers to the “how big” question makes the future feel more complicated than simply “bigger”.

Some are adamant that new models of care are the answer. One GP was clear with me on Twitter recently, “ACO/MCP are the future of NHS and community care. Call them what you want but GP HAS to be core and influential within them”. In episode 66 of the General Practice Podcast Tracey Vell, LMC lead in Manchester and intimately involved with the development of the ACO there, started to describe how general practice would look differently within the new models of care. In this scenario, scale is needed primarily for practices to be able to partner with the rest of the system.

And what about the impact of technology? How long will it be before we no longer go to the doctor, but the doctor (virtually) comes to us? We are now tiptoeing over the boundaries between health and social care, through the introduction of social prescribing and the like – is that just the beginning? Will surgeries develop from health centres into something more akin to community centres? Has the general practice practitioner already been replaced by the general practice team? How will the shortage of GPs shape the future of the primary care model?

These are all questions we are going to be discussing in our first ever live event. We are bringing together some of the most interesting guests (see the Programme here) we have had on the podcast to learn from their different experiences of re-shaping general practice, often in very different ways, and to debate what the future of general practice will look like and how it will develop.

If you are interested in understanding what the future of general practice will look like, how we will get there, and in contributing directly to the debate then register for this conference today. The future of general practice remains uncertain, but this is a chance to develop a compelling and coherent view of what that future will be.

Before I moved into the world of general practice, I used to live in the world of service improvement. It was a strange world, with its own language, traditions and practices. I kind of liked it, and look back on it fondly sometimes as you would when you remember a great place you once visited, like that trip to Sydney in 2003 when England won the rugby world cup, where they put beetroot on their burgers and thought calling me “blue” was hilarious on account of my red hair.

Anyway, in the service improvement world there is an ongoing debate about which type of change is best: should you go for small-scale continuous improvements, or a big bang change? In the world of general practice we are now facing the same question: can we adapt the existing model of general practice through incremental improvements into something different, or is a more radical approach required? Evolution versus revolution.

In the improvement world they use the terms “kaizen” (for evolutionary incremental improvement) and “kaikaku” (for revolutionary radical improvement). In the GPFV, high impact action number 10 is; “Develop quality improvement expertise”. Some believe this is the most important of all the actions because it gives practices a mechanism for making the other changes successfully. It includes techniques such as “plan, do, study act cycles” (or “PDSA cycles”) which encourage rapid cycles of testing of changes to enable successful adoption. This, and the techniques like it, are based firmly in the kaizen school of incremental improvement.

I have recently questioned whether the GPFV is failing to have the desired impact because it is trying to tackle each of the problems individually, rather than creating a clear vision for the future. A number of responses have challenged this, suggesting in particular that if all of the 10 high impact actions were implemented in a single practice that in itself would constitute our required vision.

But would it? If every practice implemented each of the 10 high impact actions, in a structured, incremental way, would the current problems of general practice be over? Certainly life would be better, but would it be enough?

Where they got to in the improvement world is that it is not an either/or. Big bang change is needed to break paradigms and elevate the awareness of people to a higher level of understanding. It is needed in addition to continuous improvement, not instead of it. While some problems can be solved by incremental improvement, others do require radical improvement to start with.

The challenge facing general practice is such that I don’t believe incremental improvement on its own will be sufficient. It needs kaikaku as well as kaizen. While the 10 high impact actions are an important part of the transformation needed in general practice, they are not the totality of it. I understand the GPFV is more than the 10 high impact actions, but if they are the element that provide the vision of the future, my contention remains they are not enough and a more radical transformation is needed.

According to a recent article, in as many as 1500 practices (nearly 20% of all practices) the partners are earning less than the salaried doctors. If this is true (and I have no reason to suspect it is not), then it means the business model that has served general practice for so many years has finally run its course.

If salaried GPs earn can earn more than partners, without the responsibility, risk or workload of being a partner, then there is very little incentive for GPs to become partners. Instead there is a strong incentive for existing partners to become salaried.

But the existing business model requires partners in order to continue. If all GPs choose not to be partners, no one is left running the business. The obsessive focus on the total number of GPs is blinding us to the critical demise in the number of GP partners.

There are two schools of thought as to how this developing crisis should be handled. One is to take the line that GP practices are in fact private businesses, and that the NHS should leave it to the market to resolve the challenges of ownership. If GPs no longer want to run their own businesses, then let’s see who does. This will leave us with a smorgasbord of private providers (Virgin and the like), acute trusts (building on the example in Wolverhampton where the acute trust is now running a number of practices via APMS contracts), community trusts (like the Willow Group, in Gosport, Hampshire), general practice “chains” (such as Modality and Lakeside), alongside general practice operating within the new MCPs and PACS of the new models of care.

Is this the future we want? Attempts to introduce a market to the NHS have not impressed to date, and it is hard to believe this diaspora of provision will serve the population well, and provide a solid foundation for the delivery of transformed out of hospital care.

The second school of thought is that there should be some form of intervention. This would require a clear definition of what current/future sustainable general practice looks like, including the business delivery model, and support provided for this to be delivered. We change the model of general practice in order to make partnership attractive again.

The impact of the GPFV has been limited because it has lacked a clear vision for the future of general practice. It has shied away from defining what the future needs to look like – presumably in an attempt to preserve the autonomy of practices (or even the market) – and has not been brave enough in its delivery of support (practices can choose the bits of support they want from whom they want etc).

This is in stark contrast to the Midlands Health Network in New Zealand. Their response to the challenges facing general practice was a to create a very clear model of care, that included patient call centres, a different skill mix, use of technologies, and improvements to the business model. They recognised the management skills in practice were primarily in operations rather than in transformation, and so they provided support to their member practices to introduce the changes over a six month period.

Helen Parker, one of the local leaders, describes this process in more detail here. They called the programme the Health Care Home and practices have to graduate to become a Health Care Home (they can’t simply decide to be one). The programme is systematically creating a sustainable future for the member practices.

The current model of general practice is at the precipice and hanging on by its fingernails, and it won’t be long before it lets go altogether. Carrying on the way we are now is a default decision to allow the market to decide the future form and structure of general practice. Instead, action is urgently required to create our own version of the Health Care Home, to support practices to implement it, and to preserve and strengthen the general practice service that forms the cornerstone of our NHS.

For me, one of the biggest strengths of general practice is its independence. It contracts with the NHS, but is not part of the monolithic NHS structure. For some this may feel like a technical difference (after all GP practices can still access the NHS pension, and they are funded with taxpayer money) but for someone who has spent 20 years working in the NHS like myself the difference feels much more fundamental.

GP practices are bound by the terms of their contract with the NHS. But within the boundaries of those terms they are free to innovate, make changes, and take whatever decisions they want to improve care for their patients and the working lives of their staff. This is in stark contrast to NHS organisations that are bound by NHS-wide restrictions, ways of operating and approval mechanisms that often stifle innovation and directly impact on culture.

It is now widely accepted that GP practices require more money – whether they are funded directly or through a contract. Moving away from the independent contractor model is not the answer; it will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Their independence is not a cause of those problems, but rather is the only reason GP practices have been able to continue the way they have despite the current pressures.

Yet, sadly, the independent contractor model is teetering on a knife’s edge. I visited a practice recently that a year ago was a relatively stable, well-run, 4 partner and 7500 population practice. Within the space of two weeks two of the partners resigned. One was retiring, and one was emigrating to Australia. A few weeks later a third declared they were also resigning as they wanted to become salaried. This left a single GP, who had neither the skills nor the desire to be the sole partner of the practice. She wrote to the CCG informing them of the situation and declared that if a solution was not found she would be forced to hand back the list.

This scenario and others like it are being played out throughout the country. The inability to recruit GP partners is rising to the top of the challenges facing GP practices today. Every resignation of a GP partner creates panic within practices, a sense of being trapped, and a fear of being the one left carrying the costs of closure.

The recent push to secure 5000 new GPs, whilst unlikely to be achieved, has brought new GPs into the profession. But many of these GPs are choosing part time or portfolio careers. The competition for new GPs is pushing up the pay for salaried GPs. The new extended access and A&E based services provide well-paid, flexible alternatives for new GPs, further increasing the challenges of recruitment for practices.

The risk is that, unconsciously, we are creating a system that rewards salaried GPs and punishes GP partners. By not intervening, general practice as a profession is risking its independence. Without GP partners, there are no businesses that can deliver against the contracts, no practices as we know them today. The NHS will have to directly deliver the service. Once independence is gone, it will never be regained.

I do not believe GPs, even new GPs, would actively choose to give up their independence. I believe it is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

We need to make becoming a GP partner more attractive. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. In a tougher financial environment, we need to make sure GPs are given training and support to be confident to take on the challenge of becoming a partner. The one afternoon designated in the current GP training programme is insufficient.

Here at Ockham we are taking a step (albeit small) to fill this training gap. On Tuesday July 4^th at 7pm we are holding a free event in Central London on being a GP partner. Join us in person or on twitter (#gppartners) – find out more details of this unique event here. Unless we take action now, general practice will lose its independence.

Enough with the analysis and breast-beating, pleads Ben Gowland! As the system finally wakes up to the crisis in General Practice he posits that there is at least one reasonably easy solution which no-one has yet tried.

The Kings Fund have published a new report, entitled ‘Understanding Pressures in General Practice’. The immediate reaction in General Practice I am sure will be a weary shrug. They know what the pressures are. Their frustration lies in the amount of time it has taken the system to recognise it, and a prevailing sense that further analysis of the problem does not seem to lead to help and support that makes coping any easier.

There could be a real benefit to the quantification of the problem. There has been a 15% rise in consultations from 2010/11 to 2014/15, based on analysis of over 30 million contacts. This is driven by an increase in the number of consultations per registered patient per year from 4.29 to 4.91 over the same period. The benefit would be if this led to an increase in the funding per registered patient.

But the money has already been promised, through the General Practice Forward View (my take on that here). This report comes two weeks too late. For GP practices, the time now is not for further analysis of the problem, but for the development of solutions. We already know what money is available and what the policy makers are offering.

Ultimately it is now down to GP practices themselves. The GP Forward View is out, and it is decision time. But, realistically, how can GP practices possibly take a grip of this agenda? How will they find the time? When some GPs respond to surveys putting the need to be able to take a toilet break at the top of their wish-list, it is hard to imagine practices being able to create the necessary capacity.

There is one place that help could come to General Practice from. There is a group of GPs who understand the challenges General Practice faces, who know how the system works, who have relationships with different healthcare organisations across the system. These are the GPs working in CCGs.

These GPs work in CCGs because the CCGs pay them to do it. If they returned to General Practice they would lose both the funding and the protected time to really help. So right now the GPs that general practice needs are crusading the cause of CCGs, tackling the problems of the system. But while they are away, home is burning. At this rate, there may be nothing left to come home to.

The time has come for a really practical step. CCGs need to identify a core group of GPs that they will second back to General Practice, and fund these secondments. The job of these GPs will be to work with local practices to help them navigate a way through the post-GP Forward View landscape, and support the development of a strong local General Practice.

If General Practice really is at the heart of local Sustainability and Transformation Plans, it is a perfectly reasonable step for CCGs to take. If GP leaders in CCGs really want to make a difference, then it is time to focus on General Practice itself. Not from within the confines of the CCG offices, but out, hand in hand, with the practices who need the help.

The pressures in General Practice are now understood and documented. It is time for action. As Benjamin Disraeli said, “Action may not always bring happiness, but there is no happiness without action”.

After years of studying General Practice, Ben Gowland has achieved something that has eluded many great scientists: he has found empirical evidence that parallel universes exist…

I have recently discovered evidence of a new universe, centred on Planet Alpha. Planet Alpha appears, to all intents and purposes, very much like our own planet. The inhabitants breathe an oxygen/nitrogen-mix, the humans are bi-pedal and no-one can fully explain the attractions of Donald Trump.

But Planet Alpha demonstrates some marked differences from Earth. It is overly endowed with policy wonks and Whitehall mandarins, a disproportionately large percentage of its movers and shakers have never held a real job and, tragically, many of its citizens suffer from selective deafness.

It is in Planet Alpha‘s approach to General Practice that we can really see the differences between them and the planet inhabited by you and me. On Planet Alpha the problems of General Practice are that it is not available 7 days a week, that not every GP surgery is offering Skype appointments and, therefore, not ‘embracing technology’, and that it is not uniformly operating at scale.

On Planet Alpha the push is to “modernise” General Practice using an army of robotic entrepreneurs with unlimited private equity that is hanging around just waiting to be invested in primary care. On Alpha there are huge efficiency savings to be made by using other professionals to support GPs and, ultimately, make them redundant. But, frustratingly for the policy-makers, many of the Alpharian GPs won’t get their acts together by offering more modern services such as 24/7 access to primary care through supermarket-like chains of super-practices stretching across the country.

Things are very different on Planet Beta (also known to scientists as Planet Reality). Beta is inhabited by GPs and practice managers with very different problems. On Beta demand has skyrocketed to unmanageable levels. Staff are leaving and there is nobody to replace them. Indemnity costs, regulation costs and locum costs are forever rising, while PMS reviews and the withdrawal of MPIG protection have stolen income away. Many staff on Planet Beta are at breaking point.

GPs on Beta know their premises are too small, are not DDA compliant and they constantly worry about the future. They look for the queue of investors waiting to sign cheques for them – but it never materialises. Increasingly sick and demanding patients arrive in their surgeries with sheets of conflicting information downloaded from the internet. The GPs want to make changes, but they don’t have time to meet the other GPs in their own practice, let alone anyone from the outside world.

Parallel universe Alpha is a much happier place because Health Ministers there are currently working to manufacture 5,000 new all-singing, all-dancing GPs to populate their alternate world and bring joy and relief to all concerned.

My research has left me reflecting; isn’t it a good job that parallel universes remain parallel and never intersect? Aren’t we lucky that the hard-pressed GPs on our own planet won’t ever have to meet the top-down loving, one-size fits all, single-minded-against-all-the-evidence autocrats on Planet Alpha? Wouldn’t it be truly awful if the Alpharians set the strategy and made the policy decisions for our own GPs to follow?

I am a bread maker. I know which ingredients I need to make the perfect loaf. I know how long it takes. I know how much the ingredients cost, how much of my time I need to put in, and how many loaves I need to sell at what price to make a living.

As a bread maker, I know my customers. I know if I make really great bread I can sell at a price higher than that in the supermarkets because my customers appreciate great bread. If the cost of the ingredients goes up, I can raise my prices and my customers might not like it but they will understand. I can still make a living.

In the NHS the life of a bread maker is much more complicated. When I sell my bread to the NHS, I am not selling it to my customers (the people who eat my bread). I am selling it to “commissioners”, who are buying that bread on behalf of patients. The job of commissioners is to make sure patients get the best possible value for the money invested by the government in the NHS, and they take this very seriously indeed.

Problems arise when the cost of my ingredients go up. I say to the commissioners, “the cost of flour has gone up, and so I will have to raise my prices”. But according to the commissioners this is my problem. They insist that I make more bread for less money, despite the rise in the cost of ingredients.

So what do I do? I can either make lower quality bread, putting less care and attention into each loaf. Or I can work longer and longer hours making bread, and pay myself less and less money to offset the rise in the cost of ingredients. Eventually, I have to do both.

I go back to the commissioners and say that I can’t carry on. My bread is no longer of the same quality and I am close to burnout.

Finally, they listen. They say they understand the problems I am facing. They say they are going to give me more money for my bread. On one condition: that I make bread 7 days a week. Patients should have fresh bread 7 days a week they tell me, and that is what they want in return for the extra money.

I say, “But I need the extra money because my costs have gone up. My costs will go up even more if I have to make bread 7 days a week. My business will still be in trouble”. “Money is tight for everyone” the commissioners reply, “we need a return for the extra money we are investing”.

I don’t understand this logic. If flour costs more, I need more money to make bread. I cannot absorb the cost and still make great bread and still make a living that will support my family. Sometimes costs go up. Sometimes people have to pay more for the exact same thing. When I sell directly to customers they understand this.

I agree with commissioners that patients should have fresh bread 7 days a week. I am happy to work with my fellow bread makers to work out a way that we can do this between us, and as long as we are reimbursed for the costs of doing it then we can provide it. But not now. Not while my business is facing such severe challenges. If commissioners paid more money so that I could meet the costs of making bread, and I could get my business back on track, then I would be at a point where I could work out how to make fresh bread available 7 days a week. But not right now.

I would be happy to agree to change the way I make bread in return for extra money. I would be happy to explore how I could find different types of labour, work with other bread makers and other organisations, and find ways that would enable me to still make great bread at lower costs. If the commissioner would invest extra money to help me make these changes I would be up for the challenge.

But if nothing changes, I do not think I will be able to make bread for the NHS any more.