One of the challenges that representatives of general practice are often given, whether it is explicitly or implicitly, is to increase the funding general practice receives.  But are they going about this the right way?

The system is pushing for more and more of general practice funding to come via Integrated Care Boards (ICBs).  The Fuller report was accompanied by a letter signed by all of the 42 ICB CEOs asking for exactly this, and now Claire Fuller herself has been made Medical Director of Primary Care at NHS England.  It will come of something of a surprise if we don’t see at least signs of this shift when details of whatever is to succeed the current 5 year contract are finally published.

At the same time, many ICBs are now starting to get their heads around their own local enhanced services (LESs), and we are beginning to see changes to how these services are commissioned. The desire for more activity to take place ‘downstream’ (ie outside of the acutes) means potentially more activity for general practice.

What all this means is that the role of the system representatives for general practice is becoming increasingly important, and is likely to have real financial consequences for the service.  But how should these representatives be approaching these discussions?

System funding has for many years been weighted in favour of NHS and in particular acute organisations.  If a hospital trust spends more money than it has then it shows up as a deficit, and funding has to be found to pay for this deficit.  In this way acute expenditure has risen year on year for many years – not because it was agreed in advance, but because during the year more money was spent than was available.

Of course, general practice does not have this luxury.  Liability for any overspend does not revert back to the system, but rather falls on the partners themselves.  The net result is that general practice absorbs its own pressures, right up until practices reach breaking point and have to hand back their contract.

We are in a situation now where there has been activity growth in core service delivery in both the acutes and general practice, but much more of that growth has been funded in the acutes because of the way the system works.  A key part of the issue is that the growth in activity within the acutes is much more visible.  Every A&E and outpatient attendance, admission and operation is individually recorded and reported into the system.

In general practice, this activity remains largely invisible.  Hard as it may be to believe not only does the system not see it, some believe the pressures the rest of the system is experiencing are due to general practice not pulling its weight.

The first challenge for the general practice system representatives is to make this activity visible.  Not additional activity, core activity.  Not as a one off, but regularly and consistently.  Instead of wondering what general practice is up to, the system needs to be as clear on the pressures in practices as they are on those in A&E.

The system has a tendency to look at any growth in general practice funding as requiring something additional in return.  There is always more work attached.  This is the mindset that has to change.  What local general practice leaders need to do is establish that the core general practice workload is both unsustainable and continuing to rise.

This requires organisation, coordination and effective joint working.  General practice representatives cannot do this on their own.  Practices need to work together more effectively with their representatives if they are to exert any real influence into the system.  Because very soon this influence will start to have direct financial consequences for practices.