When even private providers start backing out of delivering the GP contract, as now Operose Health has done, it does point to a lack of sufficient funding in the contract.  Indeed, it begs the question as to how GP partnerships are able to make a living from the resources that are on offer.

The sustainability of GP practices is more precarious than it has ever been.  The 2019 contract has not served practices well, as it did not provide sufficient funding to cover the inflationary increases of recent years, and most practices are not set up to be able to make the most of the additional resources which are all going via PCNs.  We are now seeing real financial challenges biting in many practices.

The last time this happened in 2016 there was a national response in the form of GP forward view, which did inject some much needed additional funding into the service.  At least the government and NHS England felt the need to act.  Worryingly, we are seeing no such signs now.  The final 2 years of the 2019 contract were imposed on the service by NHS England.  Zero concern has been shown for the financial challenges this would inevitably cause practices.

Why is this situation being allowed to develop?  For as long as I can remember there has not been an imposed, non-agreed contract for general practice, and then suddenly we have two in a row.  What is behind this unwillingness to fund core general practice properly?

I can only hypothesise as to the cause.  The only reasons I can think of are these:

1. The government may believe general practice has been overfunded. There exists a school of thought that general practice made money out of Covid and the vaccination programme in particular, that the 2019 contract has invested significant funds into the service at a time when very few areas were receiving any new funding, and that additional resources given to practices serve only to line the pockets of practice partners.  It may be that there are some in senior office who, incredulous as it may be to those trying to keep practices afloat, are genuinely holding onto this as a belief, which in turn has led to the lack of any additional monies coming into general practice.

2. Policy makers may believe by squeezing funding at an individual practice level they can force practices to operate at larger scale. The Fuller Report action on supporting sustainability of primary care states, “Support primary care where it wants to work with other providers at scale, by establishing or joining provider collaboratives, GP federations, supra-PCNs or working with or as part of community mental health and acute providers” p36.  Maybe we have entered an era of stick not carrot for practices to operate at a larger scale, by reducing funding at the level of the individual practice and making the need for shared services unavoidable.

3. It may be part of an agenda to nationalise general practice. We have seen politicians of both persuasions in recent months declare that the partnership model is coming to the end of its life and that new options need to be introduced. Equally we know that the NHS cannot afford to buy partners out of their existing contracts, and so maybe the plan is to make delivering the existing contract so unattractive and so financially difficult that they create an environment in which partners will choose to willingly give these contracts up.

4. The centre may want to reduce the amount of funding that has to be transferred to ICBs when general practice funding shifts from national to local. Now there are some pretty big ifs included in this, but we know that the push from the Integrated Care Boards is for general practice funding to come via them (as evidenced by the Fuller Report and accompanying letter) as opposed to via the national contract.  If NHS England is seriously considering this it is likely to want to ensure the amount of funding it has to transfer is minimised, and so squeezing the contract ahead of any such transfer makes sense.

5. Senior leaders may have confused integrating primary care with the sustainability of core general practice. The Fuller report is striking in that it works to solve a problem that general practice does not know it has (how it is ‘integrated’ with the rest of the system), and explicitly does not concern itself with the level of funding general practice requires (“the existing legislative, contractual, commissioning, and funding frameworks …were out of scope for this stocktake” p27).  Yet when asked what the plan for general practice is, senior leaders will always refer you to the Fuller report.  Somehow the sustainability question may have got lost underneath the current focus on access and neighbourhoods.

I cannot think of any other possible reasons (but do let me know if you can!), so it must be one or a combination of these reasons.  Generally faced with a choice between cock up and conspiracy I generally lean towards the former, as the top of the NHS is not well known for having (never mind delivering) clear strategies.  On the other hand the recent contract impositions and using parliament to enforce changes to the GP contract does seem to signify intention.

Whatever the cause, the reality is that practice sustainability is not a current priority for politicians and senior leaders.  If this does not change in the near future the number of practices getting into financial difficulties is going to escalate.  Maybe that is the point that we will find out the real reason behind the current situation.