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Federations could provide GPs with a big idea to unite around

Five years to save general practice. It's not quite the 24 hours Tony Blair warned voters they had to save the NHS, but it's still one of the more dramatic pronouncements made by a senior GP leader in recent years.

RCGP chair Dr Clare Gerada told Pulse's debate on the NHS reforms that if the profession didn't take action soon, it would be too late to prevent a decline into US-style family medicine – deprofessionalised and second class.

Her concern is partly that health secretary Andrew Lansley's reforms will subsume GPs' professional judgment to the greater cause of restricting referrals and balancing budgets. And specifically, she is worried plans to privatise NHS management will leave puny, under-resourced clinical commissioning groups with no choice but to rely on large corporations for commissioning support, through a ‘health maintenance organisation' model that views every GP referral as a failure.

 If the RCGP chair's warning is eye-catching, so is her proposed solution, particularly as it is also being trumpeted by the BMA in a move that must have been co-ordinated for maximum impact. Dr Gerada and GPC deputy chair Dr Richard Vautrey told Pulse's roundtable they wanted CCGs to rip up the rulebook and think bigger than commissioning organisations have ever thought before – by merging until they reach a minimum population size of one million, and a maximum perhaps as high as five million.

These giant bodies would be big enough to employ their own managers, without needing to rely on big consultancies, and to cope with the huge financial risks the NHS will face in these cash-constrained times.

The need for CCGs to buttress themselves against risk is revealed all too starkly by our investigation this week, which finds two-thirds are behind budget, and that GP commissioners in 29 areas have built up combined debts of nearly £30m since April. The roundtable heard contrasting views about whether GPs were equipped to lead the NHS as it enters its choppiest period.

Dr Gerada was being provocative when she described the faith shown in GPs as ‘touching', but our figures suggest it would be unwise to assume GPs will automatically run a tighter ship than PCTs.

The proposed super-CCGs would be powerful enough to employ the high-quality managers they will need for financial competence, and to finally take on the vested interests in secondary care. But there are problems with such a plan – as the commissioning enthusiasts round the table were keen to point out.

However much super-CCGs involve their localities, such huge organisations will inevitably feel distant to the average practice. So how then to get the grassroots involved in shaping the health service?

One answer is so-called ‘provider reform' – GP practices joining up in federations to build capacity in primary care, as providers, rather than commissioners.

It's a model pushed not only by Dr Gerada, but also by the man with whom she has seemed locked in battle over the last year, NHS Future Forum chair Professor Steve Field.

Could it be that general practice has finally found a big idea around which it can unite?


Exclusive: GP leaders debate the NHS reforms