We know General Practice is in crisis. We know NHS England has published the GP Forward View. We know more money is on its way (despite arguments about how much!). But the curious thing is there is no clear direction for GP practices to follow.

I spoke recently to Dr Maureen Baker, Chair of the RCGP, (you can listen here) and asked her whether GP practices should now be looking to operate at scale. Her response? “I don’t think all practices will have to get bigger”. But some, presumably, will. It depends.

I asked her whether GP practices should be looking to take an active role leading the integration agenda or simply participating as others (such as the local community or acute trust) take a lead. Her response? “I don’t think it matters too much whether GPs are doing it or whether GPs are coming on board… It doesn’t have to be GPs that design it, lead it, run it.” Again, it depends.

Indeed, Dr Baker’s own summary for GP practices was they must look first to their own survival, but then consider that, ‘There is a range of ways of doing things… there is not a best way to do it”.

The GP Forward View (GPFV) in many ways reflects this. There is a huge reluctance to impose change upon General Practice, but at the same time a recognition that change is necessary. From an individual GP practice perspective, it has ended up almost as a smorgasbord of ideas and opportunities that can feel both overwhelming and lack the collective coherence necessary to create a clear plan for the practice.

GP practices have to sit, poised, ready to respond to expected announcements about deadlines for estates proposals, about funding for pharmacists and mental health workers, about the programme for online consultation systems, and about any local investments in extra capacity. Information drips through about each individually, as local commissioners await guidance from on high.

Without doubt, the GPFV brings opportunities for GP practices. But these opportunities do not sit together in a coherent narrative. There is no clear direction, no route map for practices to follow. It just depends.

I was working through with the GP partners of a practice recently to understand how they could tackle the challenges they faced, and what their plan should be. It was hard.   The problems facing General Practice have not gone away, and continue to worsen. Next year looks more challenging than this year for the practice. Opportunities exist, but they feel intangible, opaque, and like they are within the control of someone else and outside the control of the practice.

The partners reflected in the past making these decisions had been easier. There had been clarity from the PCT, or the Health Authority, or whoever the commissioner of the day was, as to the proposed direction for General Practice and what they wanted each practice to do. This does not exist today. Even within the same geographical area GP practices face challenges to lesser or greater extents, and the required response varies. It depends.

But no-one is helping practices work out what their individual response should be.

You could argue the lack of a clear direction is a good thing, as it provides choice and freedom for practices, and empowers practices to be masters of their own destiny. I wonder, however, whether we have taken this too far, and as a result have created an almost impossible task for practices who lack the headroom and time to navigate through such difficult terrain. My sense is many GP practices want and need leadership – someone to say this is the route you have to follow, and if you do this it will be ok. General Practice needs a route map.