General Practice is in a difficult place.  Worse is that politically it is being backed into a corner, and without action things are likely to become more difficult still.  What influence does general practice have, and can it impact national decisions about its own future?

In 2019 a five year deal was agreed including above inflation increases in funding for the service, alongside significant new investment via PCNs.  All was fine until inflation skyrocketed beyond 10% and what seemed like a reasonable deal in 2019 with hindsight now looks like a very bad deal indeed.

The GPC arm of the BMA tried to negotiate further increases to match the inflationary pressure, but the government/NHS England response was simply to impose the terms of the previously agreed contract.  This happened in 2022/23, and then again this year for 2023/24.  Last year there was no concrete reaction from the profession, and so far this year there has equally been zero response.

2023/24 marks the final year of the 5 year deal agreed in 2019.  NHS England has already made it clear that should no new deal be agreed then the terms of this current deal will simply be carried forward.  Would the service be able to survive taking a real terms cut of over 5% for a third consecutive year?

Which begs the question of whether a new deal can be agreed.  The behaviour of NHS England and the government in years 4 and 5 of this contract should make the service extremely reticent to enter into another 5 year deal, but one suspects that is what will be on offer.  Once again it will no doubt be front loaded to make the initial offering attractive (or at least more attractive than continuing with the current deal), but the pain will inevitably come as the time of the agreement progresses.

We know from the Fuller Report that the national direction is for PCNs to ‘evolve into’ Integrated Neighbourhood Teams.  This carries with it the huge risk that the additional investment gained over the last 5 years into general practice through PCNs could be lost as that resource is shifted sideways into NHS trusts and out the control of practices.  We also know from the Hewitt Review that the push is to move funding away from the national contract and into local contracts.  More on why that will be ultimately detrimental to general practice can be found here.

So if the service would generally be against another 5 year deal, a shift of PCN resources out of general practice, and a move away from a national GP contract when we know all of these things are most likely on their way, what action is general practice taking nationally now?  While we all hope that behind the scenes furious preparations are underway, at present there is no visible action in train.

What about on the NHS England and government side?  Well, there is the national media campaign against general practice and the ‘inability’ to book a face to face appointment.  Instead of backing the service the government is announcing rescue plans and ‘firm action’ which implicitly lays the blame at the feet of practices.  As a result public support for general practice is at an all-time low.

Then there is the mandate for GPs to publish any earnings above £159,000.  Why would this requirement, that was dropped 3 years ago, be reinstated now?  It seems highly likely to be pre-emptive, so that any complaints the profession make against the proposed new deal when it comes can be countered with a point to whatever the number of declarations ends up being, ignoring the fact that huge numbers are earning less and that their earnings have gone down.  It is not hard to see the government using the ‘greedy GPs simply wanting more’ argument in any public dispute (just look at how they are handling the dispute with the junior doctors).

There is also the insidious emerging national rhetoric that the national GP contract is ‘broken’ and no longer fit for purpose.  It is not evidence based, but the NHS works by acting on whatever the perceived current wisdom is.  It is not an accident that this rhetoric has become fashionable just as the current contract is coming to an end.

So NHS England and the government have been taking active steps to prepare, while it seems the service has not.  There are plenty of actions the profession could be taking.  There could be some visible protest action against this year’s imposed contract.  Even if it doesn’t get anywhere it would be a marker in the sand for next year.  There could be a collective refusal to publish the requested earnings information, because why would you give your political opponent a stick to beat you with.  And there could be some form of concerted media campaign highlighting the growth in attendance numbers, the failure to increase the number of GPs, the impact of the imposed contract on practice staff (etc etc).  These are just a few, and of course there are many more actions that could be in train.

Something has to change.  General practice has to get its house in order nationally.  What general practice is really crying out for is some strong national leadership.  The service needs to unite behind a national figure, someone trusted by the profession and the public alike.  At present this seems to be lacking, and unless this is rectified quickly there could be some very dark days ahead.