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We (still) need radical solutions

We (still) need radical solutions

Editor Jaimie Kaffash argues we need a 2024 equivalent of the 2004 contract

As you may know, we recently published our final ever print issue. As part of this, we looked into the history of general practice. A big part of that was the 2004 contract.

I’m going to be incredibly simplistic about this, but the contract was generally seen as a success and was probably the high point of general practice over the past 60 years. This was principally for two reasons, and we can learn from these now.

The first reason was obvious – a huge injection of funding. And general practice desperately needs this now. As we have reported, there are GPs out of work at the same time as a recruitment crisis. This is shocking. Money will rectify this, will allow practices to recruit GPs and use other healthcare professionals for appropriate work. It really is that simple.

But I still don’t feel it is enough on its own. Because the truth is, demand is through the roof and is continuing to grow. As I have argued before, at a time of austerity, social problems are becoming medical ones. Unless all public services are funded adequately, general practice will continue to face overdemand.

This is a pipe dream. Labour have pretty much ruled out the levels of spending we saw in the early 2000s and obviously the Tories won’t fund public services.

However, even in a dreamworld where we do get public services funded adequately, I still feel that practices will struggle. The main driver of overdemand is basically the success of GPs and the health service in keeping people alive for longer (as Sir David Haslam explains so well). This is irreversible, and we certainly don’t want this to regress. But it does mean that we need to reassess what general practice should be providing.

Which brings me to the second reason for the success of the 2004 contract – the removal of responsibility for out-of-hours care. When Tony Blair first mooted this, the profession wasn’t wholly in favour. But by the time of the vote on the contract itself, GPs were overwhelmingly in favour.

You might see where I am going with this. Because the big story of the month has been North West London ICB bringing in an enhanced service that removes GPs’ responsibility for on-the-day urgent appointments. Now, I know that this has been met with almost unanimous disapproval from GPs, especially those in the area. And I completely understand the feeling behind it – to bulldoze this through with little consultation, and no real evidence it works is a terrible way of implementing such a seismic change to general practice.

But I do feel that radical change is still needed, and with radical change there will always be problems. I don’t know if this model is the way forward, but NHS England certainly feels it is.

So my question to negotiators for the next major contract is this: what is the 2024 equivalent of out-of-hours responsibilities, a part of the job that can be taken away, leaving GPs with space to breathe? Because I have no doubt we need such an equivalent.  

Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at



Please note, only GPs are permitted to add comments to articles

L-J Evans 15 February, 2024 6:06 pm

Please note that GPs still provide OOH care – the responsibility was removed from Practices.

Indeed, we are seen as the “Cinderella Service” – underfunded, underappreciated and overwhelmed – yet without us both Primary and Secondary Care would be unable to cope.

It is about time this was addressed and I hope GPCE are listening.

So the bird flew away 15 February, 2024 9:26 pm

Though hugely increasing GP profits, with hindsight we now know the 2004 contract kickstarted the fragmentation of general practice in a big way leading to where we are now, so probably need to aspire to a different radical solution.
Again, with hindsight, should have known that the ambitious Tony Bliar (who is an honourable man, for they are all, all honourable men) would come out of office securing his future wealth, sod the country..(I’m not endorsing Tory NHS policy either)

Andrew Buist 16 February, 2024 7:20 am

The view from Scotland is we would fight hard against removal of on the day urgent demand, it’s one of our key USPs and without it we are more easily replaced by other healthcare staff who some wrongly think can do our jobs. Undifferentiated care and complexity are where our huge value lies to the system and further fragmentation does us harm. In Scotland we seek more investment into core to expand the GP workforce to provide sufficient capacity to meet the reasonable needs of our population. Of course we have the advantage of a government who are somewhat more supportive if still secondary care focused.

David Jarvis 16 February, 2024 9:05 am

Oddly the acute illness problems needing a diagnosis are sort of the core of the job and probably the most interesting intellectually nay even quite fun. The other bits like trying to help the person on a hip replacement waiting list with pain (whilst not overprescribing opiates) and sicknotes. Chronically ill with bad backs and general misery is pretty grinding. This is like the hospital complaining of private providers cherry picking the easy low risk joint replacements and the hospital getting paid the same amount for the complex cases that also unsurprisingly make their output figures look worse. So if it happened in my locality I would jump to the urgent care hub as it would be easier less stressful work. What happens to all those difficult incurable chronic patients? Continuity of care is a burden to carry. The powers that be talk about it without any sign they value it in any shape or form.