General practice has moved into formal dispute with the government.  The main aim of this action is to ensure that appropriate safeguards are put in place around the new obligation to keep online consultation tools available to patients throughout core hours.  But could this action end up accelerating the demise of the independent contractor model?

The problem the profession has is that the government has positioned the current dispute around GP access, an issue that it knows is dear to the hearts of the public and important for its own political popularity.  The government, it suggests, is doing what it can to make access to general practice easier with Wes Streeting the bold champion of this cause.  Meanwhile general practice is being portrayed as “resistant to change”, “forces of conservatism” protecting a 20^th century model of healthcare, and even as “laggards”.  The government claims it is “mystified” by the decision of the profession to return to dispute.

Unfortunately, this positioning will resonate with the public.  Rather than putting the government in an uncomfortable corner, instead it allows them to talk up their narrative of leading the fight for patient access to general practice.

The problem is exacerbated because at the current time entering into a dispute means very little indeed.  The BMA has written to the government informing it of its position, but that is about the top and bottom of it.  The BMA is still advising practices that they have to make the contractually mandated changes, so by simply doing nothing the government will be able to point to its “defeat” of these forces of conservatism.  A ballot may come, but the way general practice is set up means it has no ability to collectively act quickly.

Maybe some practices will refuse to make the contractual changes.  Because the situation has been highlighted the way it has ICBs are reportedly on the lookout for such practices.  This could potentially lead to contract breach notices.  But it could also potentially lead to the system asking other providers to step in and “support” these practices, as a pre-cursor to what seems to be envisaged with the new “Multi-Neighbourhood Providers”.  Across London “integrators” (London’s version of Multi-Neighbourhood Providers) are already largely in place, so this is not as remote a possibility as it might at first appear.

Indeed, what might the dispute mean for these new Neighbourhood Provider contracts?  If the profession (because of its position of being in dispute with the government) is not part of their development, then the risk is increased that many of these will end up outside of general practice.  More worryingly, if general practice is portrayed as a recalcitrant problem that needs to be resolved, it may end up actively opening the door for others to take these new contracts on.

While admittedly less likely, there is also the possibility that the dispute (depending on where it ends up) could push the government into a position that the establishment of effective neighbourhoods (the centrepiece of their health policy) and the independent contractor model of general practice are incongruous.  While the independent contractor model makes general practice the most effective and efficient part of the NHS, it also makes it difficult to control.  The risk is that the government’s desire for control and the formation of neighbourhoods could potentially push it to abandon the independent contractor model.

The dispute the with the government has not started well for general practice.  The government is showing no signs of backing down, and it is hard to imagine that it will.  Meanwhile, the risks feel high, and it will require some deft political manoeuvring to ensure that the end result is a strong, safe and resilient independent contractor model rather than an acceleration of its demise.