Why?

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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

  1. 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.

The Power of Collective Negotiation

Even though general practice is made up of thousands of individual business partnerships it operates collectively through the GPC, which in turn negotiates the national contract.  It is important the power and value of this ability to operate collectively is understood, so that the most can be made of it moving forward.

It was over a 100 years ago that statutory recognition was granted for local committees of ‘panel doctors’ in the 1911 Insurance Act. These became LMCs, and once these had been set up the BMA established a national committee in 1912 to represent their combined interests in negotiations with the Government, which became the General Practitioners Committee (GPC).

Ever since then general practice has negotiated as a collective, and this has secured some important wins for the profession.

Right at the outset of the NHS it was the power of this committee that resulted in general practice remaining outside of the NHS on its formation in 1948 and retaining its independent contractor status.

In 1965 the profession was in crisis with morale and earnings low, and consultant career earnings reportedly 48% higher than that of a GP.  As a result, 18,000 of the then 22,000 GPs signed undated resignation letters from the NHS.  Consequently the GPC was able to negotiate the 1966 contract which addressed the major grievances of the profession.

In 2004, the biggest change to the GP contract in the history of the NHS was introduced.  Following negotiations by the GPC GPs voted on the deal, and voted overwhelmingly in support. In a BMA ballot, nearly 80% of the 31,945 doctors who voted backed it.

But the GPC has not always come out on top.  In 1990 the GP contract which linked GP pay more strongly to performance was imposed by Kenneth Clarke after it was rejected in a ballot.  In 2008 there was a contractual row between the GPC and the Government over evening and weekend opening, which led to the GPC being forced to accept the imposition of an extended hours deal.

But overall working as a collective has been positive for general practice.  The GPC has been at its most powerful when it has had a clear mandate from the profession, most often in terms of a vote.  It has not always worked, but it has always given the GPC an even stronger mandate going into negotiations.

Now we are in the unprecedented position of two contracts having been imposed in the last two years.  What the GPC is asking for in terms of its referendum (now scheduled for March) is for a stronger mandate, even if the result is a third consecutive contract imposition.  This in turn will not only strengthen their hand in future negotiations, but also pave the way for possible industrial action, and enable the GPC to turn up the heat on the government even further.

In many ways the outcome of this year’s ‘stepping stone’ contract will be less important than the outcome of next year’s ‘major changes’ contract, once the new government has been formed.  What general practice has to do right now is demonstrate that it has muscles it can flex, and make taking the profession on something the next government will be unwilling to do.

The only way that general practice can do this is by standing together.  The stronger the mandate the GPC has from practices (which means the higher the percentage of practices that are members, and the clearer the support it has for its position from those members) then the greater its influence will be.  So if you are not a member of the BMA, sign up now.

GPs or Additional Roles?

There is increasing animosity developing across general practice towards the additional roles, but it is largely misplaced.  Here is why.

The misconception is that the additional roles have been introduced to replace GPs.  This has been exacerbated by recent stories where GP practices have reduced their numbers of salaried GPs and replaced them with additional roles.  Equally locum GPs are reporting that they are finding it harder than ever to secure work, and the increased numbers of GPs in training are starting to be concerned that they will have no jobs to take up once they qualify.

In all of these cases practices are using the additional roles (funded via the PCN additional role reimbursement scheme) to cover the work that these GPs would historically have undertaken.  So it is not surprising that the conclusion that is being jumped to is that these additional roles are here to replace GPs, and it is from this belief that animosity within general practice towards them has developed.

But what this misses is the change in context.  In 2019 the biggest challenge practices were facing was workload.  There were not enough GPs to undertake all of the work required.  This in turn meant GPs were overwhelmed and as a result were reducing the number of sessions that they worked, exacerbating the problem even further.  More capacity was urgently required.

There were calls for more GPs.  First 5,000 then 6,000 additional GPs were deemed necessary to meet the workload requirements.  Despite an increase in the number of GPs in training no dent has been made in the number of GPs needed because GPs are retiring and leaving faster than the new ones arrive.  There are now 2,000 less GPs than there were in 2015.

With no increase in the number of GPs, and an ever increasing workload, general practice desperately needed more capacity.  This is the point at which the additional role reimbursement scheme (ARRS) came along.  What these roles did was provide an injection of much needed additional capacity into general practice.

Practices have needed to adapt and find ways of working that make the most of the skills of each of the new roles.  This kind of change is not easy, but gradually practices are working out how to make the most of this new resource.

But what has happened at the same time has been a squeeze on general practice finances.  Two years of imposed contracts and real terms cuts have led to a huge fall in practice profits, and if the purported contract offer of 1.9% for next year is anything to go by then the financial challenges  for practices are only going to get worse.

70% of practice expenditure goes on staff, so inevitably practices are having to look at ways of reducing this spending.  The additional roles are fully reimbursed via the ARRS, and so it is no surprise that practices are having to be creative about making the most of these roles to be able to stay afloat financially.

The additional roles provide a welcome source of additional capacity for general practice, particularly given the insufficient numbers of GPs available.  But the it is the financial situation that has driven practices into a choice between either these roles or GPs.  So our ire shouldn’t be directed towards the additional roles.  Instead it should be directed at NHS England and the government, whose failure to provide enough funding for general practice to employ the (insufficient) number of GPs that currently exists is the real problem.

It is really important that with all the pressures in general practice the service does not turn on itself.   It is not the paramedics or physiotherapists fault that practices have not been resourced properly, that the core contract is insufficient to cover the cost of GPs, or that the ARRS funds cannot be used to employ GPs.  We need the additional roles, not as a replacement for GPs but as well as GPs, and the service needs to work together to secure the funding it requires.

It is Time to Stand Together

One of the big complaints the system has with general practice is that they say it is impossible to do with business with 6,500 different individual businesses.  Indeed, one of the main rationales around PCNs was to reduce that number down and create units of general practice that mapped onto local neighbourhoods.

But the reality is the system does not have to deal with 6,500 GP practices individually.  There is one contract for all of those practices, and so dealing with general practice is far more efficient than all of the local contract negotiations that take place individually with each of the provider trusts.

While general practice absorbs its own risk and never returns a deficit to the system, the rest of the NHS is running up debts of £1.5bn a year.  What general practice has to do is absorb its costs, often by partners, GPs and the staff working in practices having to do so much that their own health starts to be affected.  Despite the year on year cuts to funding with the recent below inflation contract impositions, activity across general practice has continued to rise.

An outsider might expect the system to be grateful.  At least one part of the system is living within its means and not adding to the wider financial woes of the NHS.  But that is not how the system is reacting.  Instead what we have is a purported offer to increase the core contract by 1.9% next year. This is well below inflation, and so represents a further cut on top of all those experienced in recent years.

A local commissioner would not get away with such an offer to its local hospital trust.  Threats of cuts to essential services and (if necessary) some gentle winding up of the local MP and newspaper would soon force the commissioner into a more reasonable offer.  Yet for some reason NHS England thinks it can get away with making this offer to general practice.

Why is that? Is it because each practice is so small that individually they are not able to make the kind of noise that actually matters?  Is it because the dispersal across 6,500 different practices means the individual impact is hard to quantify and turn into patient stories?  Is it because the pain of the junior doctor and consultant strikes is worse than any that is likely to be caused by GPs, and so general practice is seen as a soft target?

The government’s response to criticisms of its failure to invest in general practice is to point to its overall increase in investment in the NHS.  While the overspend is so big not everyone can receive additional money, and so it very much looks like general practice has been identified as an area where spending can be tightened to relieve pressures elsewhere.

So general practice has to stop being a soft target.  At present it is too easy to cut money from the service, because while it is the pain is only going to continue.

The way to do that is to stand together.  A voice that is spread across 6,500 practices is not powerful.  But a single voice across those practices is.  The system might think general practice is a diverse group, but practices come together every year via the GPC to negotiate a single contract.  And the stronger the unity across the group, the greater the negotiating power.

The system wants to move to local negotiation for general practice because it understands the latent power the national collective holds.  It has been quite some time since the service has exercised this power, but now is the time.  Practices need to make sure they are all members of the BMA (whatever they think of the BMA, because unity is power), and back Katie Bramall-Stainer and the leaders of the GPC to the hilt.  Now is the time to stand together, and demonstrate to the NHS that general practice is not a soft target.

Who Should Fund GP Representation in ICSs and Neighbourhoods?

The question of who should fund GP representation in ICSs and neighbourhoods was raised with me recently, in the context of concerns that locally the funding for this currently provided by the ICS might be reduced or even stopped.  If ICSs won’t fund it should practices or PCNs fund this themselves?

The immediate reaction to a question like this is that there is insufficient capacity at practice level as it is, and so any other demands are unlikely to be able to be met, especially if they are not funded.  It is hard enough meeting the time demands PCNs place on practices, let alone anything beyond that.

But I am not sure it is quite so simple.  Taking a head in the sand approach to anything that happens outside of the walls of the practice could end up meaning that the practice is not able to survive as it is into the medium or longer term.  We know there is a push for more general practice funding to be held and controlled within local systems (rather than via the national contract), and part of neighbourhoods is about how the system and general practice work together.  Leaving decisions to others about how funding is to be used and how this integration should develop feels extremely risky indeed.

Part of the problem is that many of the ‘primary care leadership groups’ that have been set up up and down the country have been established by the ICS rather than by general practice itself.  The group has an ICS legitimacy, but not one that runs from practices up to the people sitting round the table ‘representing’ general practice.  The danger with this scenario is that it becomes a group where general practice is informed of decisions that the ICS has made (rather than actively participating in the decision making), and a place where the rest of the system can come and tell general practice all of things it wants general practice to do.

So actually any reduction or cessation of funding by the ICS for this work may represent something of an opportunity.  The choice is not a binary one of either continuing to attend system meetings or not.  If general practice is going to have to pay for this itself (most likely through development, PCN or federation resources) then it can design for itself how this is going to work.

This is unlikely to continue to involve mass attendance at ICS-controlled meetings.  Instead it is more likely to be meetings that bring general practice itself together (PCNs, LMC, federation etc) to identify priorities and coordinate (likely much smaller) representation elsewhere.

Funded or otherwise there is a need for general practice within each local area to find a way of working together as a collective and organising itself.  Since the demise of CCGs there are no longer any obvious system advocates for general practices outside of practices themselves, and a collective strategy of hoping the system sees sense is not going to be sufficient.

Ultimately it also works in the system’s interest to have a collective general practice voice so I would still expect the majority of places to be open to providing at least some level of funding for this.  But if they don’t then local GP leaders need to access whatever resources they can and get creative in building mechanisms to ensure the local GP voice is heard.

 

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