The UK LMC Conference passed a motion last week that “being prepared to walk away may be more effective than industrial action”, and that empowered the GPC to “use the threat of mass resignation to improve the NHS offer to practices”.  So what should we make of this idea of mass resignations?

General practice has a history when it comes to the threat of mass resignations.  The episode that most stands out was in 1965 when the profession was in crisis with morale and earnings low, at a time when consultant career earnings were 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.

But that was nearly 60 years ago, and only 17 years after the NHS was formed.  There was talk of mass resignations in 2001 and the new GP contract of 2003 followed, and also in 2016 prior to the GP Forward View being published.  But on neither of these occasions did the action go as far as collecting undated resignation letters.  The political context was also different then – these were both during a time when the NHS wanted an internal market with general practice driving the purchasing side.

What is different now is that there is a possibility that the resignation letters could be accepted.  The total primary care medical spend is in the region of £13bn.  If practices resigned and provided services privately to the population, and (if we take dental services as the best example we have of the impact that would have on spending) just over half of this funding could potentially come directly from patients.  This means the government/NHS could save in the region of £6-7bn by simply accepting the GP resignation letters.

While such a move would be deeply unpopular with patients, there may be a belief that the “blame” could be focussed on the (greedy) GPs choosing to leave, and there are not many ways to come up with that kind of additional funding.  It is hard to see how a largely private general practice service fits with the policy agenda of integration, but it may be that the financial advantages would outweigh the inevitable internal challenges, and many other countries function with a hybrid funding model for general practice.

I don’t believe any incoming government would want a shift from an NHS to a privately funded arrangement, but my point is that general practice should not offer undated resignation letters unless it is prepared for its bluff to be called.

I am sure it is with this in mind that the conference motion that was passed also mandated, “the GPCs to develop viable alternatives to GMS, including actively supporting GP practices to work outside the NHS”.   What would a direct funded alternative look like?  How will it prioritise continuity of care, prevention and all the other aspects that are important to general practice in a way that the current NHS contract does not?  How can it work in a way that doesn’t immediately exacerbate health inequalities but can support attempts to tackle them?

To date there has not been enough serious thought given to what this alternative could look like.  Professional negotiators use the term “BATNA” – the best alternative to a negotiated agreement.  This is what they use as their walk away option, and refuse to agree anything that is not better than this.  One of the reasons that the GPC has suffered in recent years is that their BATNA has been the continuation of the existing contract, which has worked very well thank you for the government and NHS England.

It is only by creating a more powerful BATNA (mass resignation from the NHS contract with a clear plan for what would come instead) that general practice will be able to wield any real negotiating power in the current climate.  But it is risky, because it will only work if practices really are prepared to walk away and accept that this is what it may come to, and this can only happen if we develop a much clearer picture of what this alternative future would look like.

Nearly all PCNs struggle with effective communication across the member practices of the PCN.  Despite each practice having representatives in PCN meetings, frequently practice staff beyond the practice representative are oblivious to much of what the PCN is doing.  How, then, can PCNs make their communication effective?

When considering this question most PCNs come up with a range of transactional responses. For example, we will add a section to the PCN website that all practice staff can access, with ‘how to’ guides for all the PCN services.  We will create a monthly newsletter to go out to all practice staff.  Or we will set up some additional WhatsApp groups so that people can learn about what is happening directly.

But despite the good intention, what happens is that these things make little or no difference to the awareness and understanding of practice staff of what is going on across the PCN.

The reason that these things don’t work is that communication is far more effective when it is directly between people.  Communication relies not just on the information being passed on, but also the person receiving it engaging with it.

This means that the PCN meeting is by far the most important when it comes to communicating.  The first question for PCNs to consider is whether attendees are engaging with what is being communicated in those meetings.  It is hard to believe that this is the case if the meeting is full of attendees on mute with cameras off.  Actively seeking feedback from all on issues that are raised is one way of building engagement with them.

The second step is to consider the practice representatives.  Who is coming?  Are they the right people to be attending from the practice?  Do they have influence back at the practice?  How likely are they to be feeding information back into the practice?  We may be getting information through to the PCN meetings attendees, but is it going any further?

Where this is identified as the issue, a good strategy is for the Clinical Director to attend a round of member practice meetings.  Here they can feedback the work of the PCN.  They can also stress that this should not be news to the practice as you would expect the practice representative to be feeding this back to them.  If they are open to it, you can then ask how they would like to receive this information more regularly.

Another key set of individuals when it comes to effective communication across practices are the practice managers.  A strategy that is proving increasingly popular across PCNs is for the PCN manager or Digital and Transformation lead to meet regularly (often weekly) with the practice managers.  This is particularly good because it keeps this key group of individuals engaged and up to date with what it going on across the PCN, and they in turn are best placed to ensure anything important gets onto practice meeting agendas.

The third area that can be targeted is PCN all practice events.  These can be held quarterly or bi-annually, and are best done on a face to face basis.  These are not a luxury, but should rather be considered as a vital component of PCN working.  They allow the wider membership of PCNs to review progress and agree a way forward, and (more importantly than anything else) they strengthen and renew engagement of member practices in the work of the PCN.  These events should always include a reminder of everything the PCN is doing/has done – while PCN CDs feel that practices know all this anyway, the reality is they often either do not or have forgotten and so a reminder is always useful.

Ultimately effective communication is a result of strong engagement from practices in the PCN.  Where engagement is good, communication is relatively straightforward.  It is where engagement is poor that communication is often difficult, and so rather than treat the symptom (poor communication) it is much better to treat the cause (lack of engagement).

This year is going to be tough for GP practices financially.  What will the impact of these financial challenges be on PCNs?  Will PCNs finally come into their own as a (now necessary) mechanism for joint working between practices and enabling economies of scale, or will tensions between practices and PCNs simply rise?

The scale of the financial challenge facing GP practices this year is unprecedented.  The 2% contract uplift takes no account of the rise in the minimum living wage, and the inflationary uplift of 1.65% bears no resemblance to the inflationary pressures practices are facing.  Whilst this is the third consecutive time a contract with real terms cuts has been imposed, it is the first time it has not been at least partially offset by increased investment in the PCN (the funding of which has similarly been frozen).

The impact of these financial challenges will not be limited to practices.  PCNs will also be affected.  When the finances of any organisation come under pressure then there is frequently a knock on impact on collaborative working.

How will practices respond? They will understandably prioritise core activities over any collective PCN activities.  Where resources are limited practices will focus internally and if something has to go then it will be most likely be the PCN work.

The tolerance for ARRS staff carrying out PCN work as opposed to supporting practices with their core work will most likely reduce.  It is already increasingly common to find practices calling for ARRS staff to be allocated on a ‘per practice’ basis rather than working as teams on PCN work.

Many ARRS staff were employed during and immediately after covid which, along with the lack of available space in GP practices, meant that many were employed to work virtually for some or all of the time.  But the usefulness to practices of staff working remotely is generally less than those delivering in-person services, and so now we are seeing a push for less of these virtual working arrangements.

When resources are limited organisations generally become more risk averse.  So while the opportunity for joint working and initiatives for collective benefit via the PCN still exists, the willingness of practices to put time and resource into a new way of working with an uncertain outcome is likely to be less.

Shared ventures require some form of shared overhead in order to be effective.  But practices will increasingly see this as being an unnecessary expenditure, with a growing belief that it would be cheaper (more profitable) for the service to be delivered in house by the practice.  As a result practices who were previously supportive of PCN or federation delivered services (like enhanced access) are now starting to consider providing these services directly themselves.

Financial instability also impacts trust.  When practices doubt whether the other practices in the PCN can fulfil their obligations or contribute meaningfully to shared goals then when times are tough commitment can wane quickly.  Practices that have this sense that they are “carrying” some of the other practices in the PCN are likely to pull back from PCN activities when they come under financial pressure themselves, with obvious consequences for the PCN as a whole and its ability to function effectively.

So the natural tendency of such an environment is to impact negatively on collaborative working, but this does not mean that it is inevitable.  It makes good logical sense for practices to pool resources and to share the burden of financial constraints as together they can achieve more than they can individually.

But PCNs will need to be focussed.  Ignoring the financial challenges faced by member practices will not work.  Instead, PCNs will need to take a much more practice focussed approach to collaboration, focusing on measurable outcomes and making a tangible impact. Activities and investments will need to be aligned with objectives and priorities agreed with practices in advance.

A tough financial environment is difficult for everyone.  Working together in PCNs is a viable strategy for practices to cope with this environment, but it will not happen by itself and PCNs will need to work hard to prevent the default option of practices withdrawing from collaborative work and focussing on themselves.