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.