Dr Katie Bramall-Stainer is the current Chair of the BMA’s GP Committee in England, and has led the negotiations on this year’s contract.  It is her first year in the role, and she has been much more visible than many of her predecessors.  Recently she gave an interview on the Talking General Practice podcast, where there were some very interesting insights into the recent contract negotiations.

The first is that on numerous occasions she referred to the reason for the underfunding of the core GP contract and the refusal to consider cost neutral suggestions as “ideological”.  At different points in the interview she stated that it was “not logical” and the decisions were “intentional and predetermined”, that there was a “perverse ideology behind it”, and that it was an “ideological dismantling” of the profession.

So something  more than just a lack of available of funding is going on, although frustratingly there was no further probing on the exact nature of this different ideology.  It is, however, hard to think that this is anything other than a belief that general practice should operate at a larger scale as a full part of the NHS, and that the partnership model (despite being the most productive part of the NHS) has somehow run its course.

The second insight was that there is much more hope nationally that the DDRB (Doctors and Dentists Review Body) will recommend a positive uplift for general practice.  Dr Bramall-Stainer reported that they were able to put forward a very cogent case for the 8.7% uplift the GPC has calculated as being necessary to return the profession to 2019 funding levels, and that this was well received.

The caveat on this is that the DDRB recommendations are not made until the end of June, and even if these are positive they then rely on the government accepting them, which it may not be inclined to do given the competing priorities for government funds in the run up to a general election.

However, if sufficient noise is generated by the result of the current referendum, along with any media coverage of the LMCs conference and GPC face to face roadshows planned for early in the new financial year, then the government may be more open to the DDRB recommendations.  As Dr Bramall-Stainer herself explains, the strategy is to give the government every opportunity to change the course this is moving without the need for industrial action.

But industrial action is on the cards, and what Dr Bramall-Stainer also gave was an insight into what this would entail.  She acknowledges that industrial action is difficult for GP practices, who rely upon a trusting relationship with their patients.  Damaging this trust in the pursuit of additional funding is a pill many practices would find hard to swallow, and so she is at pains to say that any action must be designed to hurt NHS England and the government, not the patients practices serve.

But this is a hard balance to strike, because ultimately if the changes do not affect patients then they do not affect the government.  What the GPC are clearly leaning towards is a mass movement across practices of only treating a safe number of patients a day.  They hope that if this is backed up by a clear enough campaign that stresses that practices are only seeing the patients that they can with the number of GPs and nurses they have then practices will be protected from any backlash, and that any ire will be directed nationally rather than locally.

Is this enough that the prospect of it will deter the government from continuing on the current course of underfunding the profession, and is it possible to enact and at the same time protect practices from any backlash?   The GPC knows it has to be prepared for its bluff to be called and to be able to follow through, so it has to get this balance right.  Understanding this is why the GPC wants to engage the profession as far as it can in designing the final shape of the industrial action it ultimately puts forward.

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.