According to a recent article, in as many as 1500 practices (nearly 20% of all practices) the partners are earning less than the salaried doctors. If this is true (and I have no reason to suspect it is not), then it means the business model that has served general practice for so many years has finally run its course.

If salaried GPs earn can earn more than partners, without the responsibility, risk or workload of being a partner, then there is very little incentive for GPs to become partners. Instead there is a strong incentive for existing partners to become salaried.

But the existing business model requires partners in order to continue. If all GPs choose not to be partners, no one is left running the business. The obsessive focus on the total number of GPs is blinding us to the critical demise in the number of GP partners.

There are two schools of thought as to how this developing crisis should be handled. One is to take the line that GP practices are in fact private businesses, and that the NHS should leave it to the market to resolve the challenges of ownership. If GPs no longer want to run their own businesses, then let’s see who does. This will leave us with a smorgasbord of private providers (Virgin and the like), acute trusts (building on the example in Wolverhampton where the acute trust is now running a number of practices via APMS contracts), community trusts (like the Willow Group, in Gosport, Hampshire), general practice “chains” (such as Modality and Lakeside), alongside general practice operating within the new MCPs and PACS of the new models of care.

Is this the future we want? Attempts to introduce a market to the NHS have not impressed to date, and it is hard to believe this diaspora of provision will serve the population well, and provide a solid foundation for the delivery of transformed out of hospital care.

The second school of thought is that there should be some form of intervention. This would require a clear definition of what current/future sustainable general practice looks like, including the business delivery model, and support provided for this to be delivered. We change the model of general practice in order to make partnership attractive again.

The impact of the GPFV has been limited because it has lacked a clear vision for the future of general practice. It has shied away from defining what the future needs to look like – presumably in an attempt to preserve the autonomy of practices (or even the market) – and has not been brave enough in its delivery of support (practices can choose the bits of support they want from whom they want etc).

This is in stark contrast to the Midlands Health Network in New Zealand. Their response to the challenges facing general practice was a to create a very clear model of care, that included patient call centres, a different skill mix, use of technologies, and improvements to the business model. They recognised the management skills in practice were primarily in operations rather than in transformation, and so they provided support to their member practices to introduce the changes over a six month period.

Helen Parker, one of the local leaders, describes this process in more detail here. They called the programme the Health Care Home and practices have to graduate to become a Health Care Home (they can’t simply decide to be one). The programme is systematically creating a sustainable future for the member practices.

The current model of general practice is at the precipice and hanging on by its fingernails, and it won’t be long before it lets go altogether. Carrying on the way we are now is a default decision to allow the market to decide the future form and structure of general practice. Instead, action is urgently required to create our own version of the Health Care Home, to support practices to implement it, and to preserve and strengthen the general practice service that forms the cornerstone of our NHS.