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The end of the GP practice as we know it?

The end of the GP practice as we know it?

Editor Jaimie Kaffash argues that NHS England’s vision of an upscaled general practice will have major implications for individual practices’ autonomy

It feels like NHS England has been trying to kill off the GP practice in private for a while now. As a reporter in 2016, I wrote a piece on an NHS England local medical director saying small vulnerable practices should be allowed to ‘wither and fail’. In 2018, former primary care medical director Arvind Madan made his infamous comments that GPs should be ‘pleased’ when small practices close.

However, it seems as though such pronouncements are becoming more public. Dr Madan’s latest successor, Dr Amanda Doyle, has seemingly gone further, and in a public forum at a House of Lords Committee hearing this week. She said: ‘One of the challenges that the current predominant ownership model in general practice gives us is that both investment and revenue flows support that model [of] an individual, practice-sized building.’ This does not ‘sit comfortably’ with NHS England’s plan for ‘scaled up’ primary care that is based on the Dr Claire Fuller ‘neighbourhood model’ that will see local health centres integrating general practice and a number of other services.

While the conversation veered towards premises and estates, the implications of Dr Doyle’s statement cannot be overemphasised. It is NHS England’s stated plan to follow the Fuller model, and this is in keeping with the integration plans that resulted in PCNs. We also know that the NHS has been trying to funnel more money through networks at the expense of practices.

But Dr Doyle’s comments present a step up in my mind. Because the idea that the current funding model is incompatible has major implications for the autonomy of GP practices – and potentially the partnership model.

Even within PCNs – and the push for more funding to be funnelled through them – the guaranteed income of the global sum ensures practices retain their autonomy and individual identities. By casting doubt on the current funding model, Dr Doyle may well be laying the groundwork to remove this funding and, with it, practices’ autonomy.

I’m all for radical ideas, and when Dr Doyle later said that younger GPs are less keen to take a partnership, including building ownership, I had to agree with her. As I have argued before, this isn’t an issue with general practice, it is a societal shift that younger people are understandably less willing to stay in the same role their whole lives. We need a way of addressing this. Separately, I think it is a good idea to review how the global sum works.   

But this cannot involve removing autonomy from individual practices – this is a red line for me. Continuity of care may be diminishing, but we can’t just give it up altogether – and that is what NHS England’s vision of upscaled general practice will do (even if they deny it). And crucially, it will take the responsibility of designing general practice away from GPs.   

As I argued last week, I can’t imagine that we will see much change in the 2024 GP contract due to the political landscape. But a new, revamped general practice is on its way at some point soon. NHS England have shown their hand – it is up to the profession to retain the autonomy of practices.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at editor@pulsetoday.co.uk


          

READERS' COMMENTS [16]

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fareed bhatti 21 June, 2023 6:57 pm

Thank you very much Jaimie . Its quite clear that whatever sensible arguments there are to retain the effective and yearned for ‘family doctor’ model ruining under the partnership model, there is a unified front to destroy it. I personally feel that it has become inevitable. The old guard has had enough and the young ones are too disillusioned. I would understand if they did blame the previous generations amongst others for not having a united enough front to stand against NHSE/HMGs etc .
Its not all the previous GPs faults but I think we have spectacularly failed at having a united sensible voice. I feel most dejected that I come across some amazing and inspirational GPs everyday, read excellent opinions in LMC letters, meet GP trainers and educators that are absolute legends,but somehow as you go higher, their voice seems completely different and often more in tune with HMG. I remember reading Dame Clare Gerada’s interview when she had recently given up the RCGP post that the partnership model of GP was outdated (or words to that effect). I also remember reading that she had a partnership share in a chain of GP practices or private GP services (ICGP was dissolved in 2016). So I think sometimes you have to let ‘it’ happen- let us really let people find out the value of GP by moving to a salaried role. I wouldn’t be sitting doing on-calls tasks and filing bloods and letters for colleagues to help despite being unwell, I would have a more structured job plan etc. But knowing history, we are going to get shafted with a poorer relative contract to our secondary care colleagues.

Dr No 21 June, 2023 10:42 pm

Yes it’s the end, if not now then very soon. The job as I’ve done it and loved it is now time-limited. The only commitment I have the energy to retain is to my partners and the patient I have in front of me. Part of the problem has been the amateurism of our negotiators over the years. They are dealing with wolves, and come to the table with moderation and goodwill. My patients would be astonished with my intemperance here. So, I say again, Fuck The Tories,

Nick Mann 21 June, 2023 10:57 pm

“Small General Practices will be left to wither on the vine”, said Simon Stevens at NHSE’s AGM in 2013, when the MPIG was removed from GPs serving deprived populations. NHSE serves to deprofessionalise general practice. It’s a project, not progress. Polyclinics aren’t any solution to the problems we have right now or in the future.

“Continuity of care may be diminishing, but we can’t just give it up altogether – and that is what NHS England’s vision of upscaled general practice will do (even if they deny it). And crucially, it will take the responsibility of designing general practice away from GPs.”

Neither patients nor the NHS will welcome Govt/NHSE’s cheap and nasty ‘vision’.

Sam Macphie 22 June, 2023 12:37 am

Dr No, have we seen you in some James Bond movie? It’s just the name seems memorable. Why not give up the fake name and use your real name: it will probably still be very memorable to everyone. Make it an additional commitment if you like.

David Banner 22 June, 2023 9:55 am

Whilst those at the top would dearly love to finally kill off Partnerships (and thus finally iron out the annoying wrinkle of GP autonomy in the 1948 founding of the NHS), they realise it would be financially ruinous to do so in one fell swoop.
Their strategy instead is to smoke us out one by one, destroying Partnerships by stealth.
. When no younger GPs want the responsibility, the surviving Partners do all they can to cling on……unifying with neighbouring Practices, employing armies of ARRS, hiring expensive locums etc, in a vain attempt to avoid “handing back their contract” and the horrific possibility of Last Man Standing bankruptcy.
Herding us all together into PCN pens and directing all new funding that way has further eroded independence.
It’s death by a thousand cuts, “evolution not revolution”, a slow strangling of a maverick Partnership model long loathed by those in charge.
Their tactics are clearly working, and they are playing the long game brilliantly.
The media bashing has done wonders in turning the public against us (our previously annoyingly high approval rating was a major spanner in the works), so now NHS leaders are becoming far bolder in declaring publicly their musings on how to dismantle an apparently broken Primary Care system and ensnare us all into a controllable salaried service.
It will, of course, be grimly hilarious watching it all crash and burn in 20 years time, when they finally realise what an absolute bargain Partnerships were (working above and beyond for our patients and partners through thick and thin) once we all insist on only doing our defined work/hours (“no cover? Not my problem!”) .

Centreground Centreground 22 June, 2023 10:26 am

The impending destruction of Primary Care is littered with certain GPs abandoning their roles within the practice and entering self serving highly paid Board and Clinical lead roles and then collaborating in policies causing untold damage to grass roots General Practice.
Currently this damaging role is being ably filled by unacceptable numbers of ineffective overpaid Clinical Directors of PCNs leading the charge to fragment GP practices whilst pocketing astronomical fees for little useful output as was seen in the Pandemic by the quadrupling of these monetary CD incentives to assist the government in the their objective to oversee the decline of the current GP model.
Unless Clinical Directors and PCNs are stopped , then Primary care will continue to decline.

David Mummery 22 June, 2023 10:57 am

The move to PCNs was always going to be a stepping stone to what is happening now. None of this is a surprise

Victoria Cleak 22 June, 2023 12:40 pm

David Banner you seem to think that there will be any form of long term memory of this or that anyone will accept they messed things up or take any responsibility.
We as a profession have failed our profession and failed our patients in letting the market model of ‘ pile em high and sell em cheap’ infiltrate and take over a system that put care before profit.
People at the top dont learn. I heard that George Osborne is still insisting that you can’t have a good health service without good finances but you can’t be productive and earning as a country without a healthy happy population either.

Guy Wilkinson 22 June, 2023 2:02 pm

The clincher will be premises.

For ownerr occupiers it will determine whether we follow the dentists into a private system or accept a cash offer from Govt and become salaried.

A Non 22 June, 2023 2:27 pm

I doubt the government is planning on buying anyone out as I read optimistically suggested fairly frequently. This is a long game. Your premises will be metaphorically surrounded and you will be starved into submission. Some will escape through retirement, some will willingly leave. All will take time. Nobody in government will be seen to make any obviously incriminating decisions. The very notion of partisanship will continue to morph, fudge and change. And as night draws in on the partnership model of General Practice as we recognised it yesterday anyone still ‘in’ business with property will be going ‘out’ of business, selling up privately or just going belly up. The government have you by your short and curly’s. Gradual fading away is the future. No big bag government money fuelled goodbye party that is certain.

Not on your Nelly 22 June, 2023 6:19 pm

The only example you have to look at is out of hours. Taken from GPs when it was well run, cheap with GPs having buy in. Now a non-existent service with NO GPs and run to the ground with gaps across the country and 10 x as expensive. GP will go the same way. history repeats itself. Idiots never ever learn.

Dr No 22 June, 2023 10:58 pm

@sam macphie – Yes I have a white cat too! It’s exactly on account of my commitment to my partners and patients that I post anonymously. It’s a shame that the professional role mitigates against public honesty, and my local reputation is good. Here I can speak my mind without alienating those patients of mine who are still Tories. Though obviously they have sociopathic personality disorder they are still my patients.

Kiki Steel 23 June, 2023 1:41 pm

What about the small rural practices? If we are going to be forced into large group practices the patients will ultimately suffer. Particularly as rural areas have little or no public transport. Policy makers sit in their central city ivory towers making decisions which are fine for big cities but don’t fit with rural areas. Look at the problems we currently face with major trauma centres (our “local” one being an hour away)!

Hank Beerstecher 26 June, 2023 5:22 pm

COI: Struck off in 2018 for not treating the CQC as colleagues after an 11 year bullying campaign by NHS England. I was the one-but-last GP to be appointed to a single handed practice in Kent in 2001. Tony Blair let the cat out of the bag to start the war on single handed practices a few months after I was appointed. One year after the appointment the chief exec told me to expand or the health authority would start a practice across the road to compete me out of business and sell the premises to move into a local shopping centre (demolished in 2015). In the GP Patient Survey our practice always ranked in the top 2% nationally, like numerous small practices: reason – you get continuity of care and more importantly appointments.

The talk about upscaling came from Sainsbury, the same supermarkets that are now downscaling. Unfortunately there are a number of ‘ours’ encouraging the policies, I had a look at Professor Claire Fuller’s (and 14 cosigners) list of references at the bottom of the document, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf – the only reference to an actual peer reviewed article recommending continuity of care, which you only get in small practices. Yes, the science behind upscaling primary care is impressively absent, but it is some noise that will keep some in receipt of public finances.

John Evans 27 June, 2023 2:46 pm

Driving forces are not evidence based, efficiencies or quality improvement.
Anticipated economies of scale will continue this process regardless of quality or value.

Knowing your enemies battle plan should be welcomed and used to the professions advantage. Messing about with PCG, PCT, CCG, ICB or even training your lesser qualified replacements in an attempt to endlessly preserve underfunded levels of service will ultimately fail, and GPs will be blamed anyway.

Look after yourself first so that you are able to look after others more effectively.

Emigrate, retire, move to salaried roles or decline partnerships especially those with property liabilities. The service will not be sustained by a salaried workforce though the blame will then be with the govt and the companies that they contracted.

Primary care will be restricted regardless – the only difference is the battering that the profession takes en route and the level of influence over workload / terms of service.

Red, yellow, green politics will promise more although ultimately won’t help you.

Decorum Est 28 June, 2023 1:43 pm

We’re Doomed! Doomed! (not joking)!