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At the heart of general practice since 1960

A tribal truce is vital to secure GPs’ future

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For historical reasons, general practice is split along many lines: sessional versus partner; GMS versus PMS; urban and deprived versus leafy suburbia. Now, though, there is another divide, and one that is currently running much deeper than the others.

The way I see it, there are two tribes are battling over the soul of the profession, and it is a struggle with tremendous consequences for the way GPs will work in the future. The first tribe – let’s call them the ‘reductionists’ – are in the ascendant.

They are the GPs who argue that general practice is full, that its open door is being abused by patients, hospitals and politicians. And this is completely understandable. Efforts to boost access and adjust ‘skill mix’ have been outflanked by the twin foes of chronic underfunding and soaring demand. General practice has reached ‘saturation point’.

Recent Government promises of increased investment of 4-5% a year do little to reverse this. As Pulse has revealed, even in five years’ time, GPs will still receive less than 8% of NHS funding as secondary care continues to suck up resources.

Reductionists look around and sees rising rates of burnout among partners, practices struggling to recruit and young GPs seeking greater job satisfaction as locums. Their solution is to stem the tide of demand by saying ‘no’, refusing unfunded work and reducing the GP role to serve the genuinely vulnerable and sick.

This is the tribe behind the recent LMC vote that backed exploring mass undated resignations if a rescue package is not forthcoming by July. You see their influence in campaigns against the continual redefining of what GPs do, the ongoing drive to burden practices with public health interventions and social work – checking patients’ boilers and the like.

But in the other corner, is a different tribe. I shall call them the ‘expansionists’. They see NHS England’s Five Year Forward View as a blueprint for extending the role of general practice and a chance to build a truly primary care-led health service. They don’t see policymakers as ‘the enemy’ and have little truck with the view that general practice should hunker down and ‘do less’.

They are the GPs that support social prescribing, welcome moves to employ physician associates and pharmacists, and view super-practices providing more specialist and community services as the future. Unlike the reductionists, they have a seat at the table with ministers and they are first in line for extra funding from the health service when it comes. And – let’s face it – they are the ones that are more likely still to be around in five years’ time.

Now tensions can be creative – every ying needs a yang – but I would argue that general practice has to find a way to call a truce and bridge the divide between these two tribes. The reductionists struggle to offer any compelling vision for the future of general practice, whereas the expansionists have no answer to how those outside super-practices can survive in the short to medium term.

And the truth is that in most GPs there is a mix of reductionist and expansionist thinking, but the current climate has tipped many into the reductionist camp. GP leaders now need to find a way to end the tribal conflict so the profession can unite in the battle for its future.

As Frankie Goes to Hollywood put it: ‘When two tribes go to war, one is all that you can score.’

Nigel Praities is editor of Pulse

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Readers' comments (16)

  • What is the basis for the assumption that expansionist are going to be around longer?

    "Reductionists" are guided by the survival instincts, while a lot (but not all) of the collaborative work is being entered into either out of desperation or as a frivolous gamble by "expansionists".

    This is a battle that is going to be won by businessmen and lost by everyone else.

    Hire the right staff.

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  • This is spot on thanks Nigel.
    I personally have felt the change from expansionist to reductionist.

    The reason is not the expanded primary care is a good thing - I think we could be excellent at managing aspects of hospital care in the community. This might include: taking control of community nursing; employing specialists not only to do clinics but to help integrate best practice, case finding and audit into the care of our registered list; integrate (ie employed by us) prescribing pharmacists to work on what we decide rather than CCG/PCT priorities.

    However, one has to follow the money, not the rhetoric, and the starving of funds is a crisis that is happening now, without transfer of resource even though the care has been transfered/dumped.

    Consider extended access - the fee for this was dropped by 60% when the coalition gov got into power, yet politicians spent the next 6 years complaining about extended GP hours and concocting eponymous 'prime minister's challenge' schemes to reprovide this at a greater cost.

    As to horizontal expansion of failing practices look at the Royal Bank of Scotland takeover of AMRO in 2007, the biggest banking deal at the time.
    It was ultimately an act of hubris right before the business collapsed in the 2008 financial crash.

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  • Perhaps the "reductionists" are the ones who have been around long enough to have been there, done that, wasted time on and survived various political reorganisations/bright ideas/hobby horses, know what is important in general practice and are prepared to fight for it. (I dispute the assertion that we lack "any compelling vision for the future of general practice").
    "Expansionists" however are new to the game, still trying to play without realising that they'll never win and even if they seem to be doing so temporarily, the game will then be changed.

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  • Has anybody noticed that the practice of Prof Field has not published GP earnings?

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  • I do suspect the 'expansionists'may wither as the pump-priming monies run out and reality bites (watch the DevoManc area particularly) , though of course some of them will move on to newer and better things, leaving chaos and poorer patient care behind in their wake, with the 'reductionists' as usual having to pick up the pieces, if they have't all retired or moved out of England by then.

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  • FACT = GP land funding has been reduced in NI from 11% to 6.5 % of NHS spend. FACT = we see 85% of all face to face contacts.
    FACT = CQC has trebled their fees.
    FACT = 50 % fall in income in 12 years per item from a profit of 6 to 3 pounds per consult [ as an example], not reductionist or expansionist.
    FACT= penance and neglect [ Mr HUNT himself]
    if you want to continue with this abuse and see more for less, please do and welcome to it.
    The DOH needs expansionists like you. Thank GOD you exist. Otherwise GP land would e long gone.

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  • I think you can be both: reductionist regarding the core service in its current underfunded form. Say no to all unfunded extra demands and review what you are currently doing for goodwill rather than funding. But be expansionist beyond that point, consider mergers, consider pitching for additional services provided they are appropriately funded.

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  • I am happy to declare myself as an expansionist. The reductionists grind me down and suck all the joy out of life. I've got a good few years at this game yet and I'd rather be surrounded by likeminded people who have a vision of a future for General Practice and can see the way out of the mess we're in. To come through the transition we need to embrace change and consider all the options for new ways of working. Reductionists are scared of change but if they don't embrace change and help shape it they'll be left behind. Adapt or die.

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  • I'm more of a reductionist. I have a vision for the future of general practice based on good clinical care and what I would like to be available when I need a GP. I embrace change when it is good but not for its own sake or because of the current political whim. I have seen too many "expansionists" take start-up payments then move on making life harder for the rest of us.

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  • "Anonymous | Practice Manager06 Apr 2016 11:39am
    Has anybody noticed that the practice of Prof Field has not published GP earnings?"

    They have but not on each surgery's website, it is in the main website for modality
    https://modalitypartnership.nhs.uk/gp-net-earnings-201415

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