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Why I removed my contribution to the future of general practice report

I welcome the publication of Policy Exchange’s new report, At Your Service, and hope that this thoughtful, provocative document stimulates an important debate.

But, as someone named as a contributor, I felt I could not have my name associated with it.

Policy Exchange contacted me to contribute, and I submitted lot of evidence in my interview of the importance of supporting the independent contractor status and increased resources into core general practice as the solution to the future of sustainable and safe general practice. Their final report did include discussion of increased funding, expanded GP voices in ICSs, and support systems for premises – all of which are among my suggestions.

But their final report supported a conclusion I am firmly against – moving general practice to a salaried model.

My response on first reading the report was to ask: ‘Is this trying to solve the problem of critical workforce shortages?’ It’s imperative that we have a clear plan to address the workforce shortages and that alongside this we have reforms that seek to improve efficiency and effectiveness. I feel that if we’re committed to this, it’s also helpful to establish interim arrangements to address the shortage of doctors and nurses. However, we must be clear about our motivations – and I don’t think this is necessarily the case as it stands. For example, the PCN ARRS was primarily designed to incentivise primary care to recruit professionals where it was deemed that there was a surplus. ARRS doesn’t fund practices to take on more doctors or nurses, but does fund them to have a chiropodist!

But a salaried model is an even worse solution. The key focus of any reform of our profession must be to improve outcomes for patients in the most cost-effective way. So, it’s important to ask if moving away from the partnership model deliver this. I have no doubt that it’s important to have a mixed economy of provision models. However, the partnership model is, in the main, cost-effective with high productivity and traditionally good patient satisfaction.

We must be careful not to throw the baby out with the bathwater. We could create a salaried system (and the suggested approaches to this are well thought-out and would be attractive) and then discover a huge rise in costs and a significant drop in productivity. For instance, undoubtably moving all practice staff onto Agenda for Change will have benefits, but huge costs.

In very practical terms, partnerships provide greater productivity and efficiency than all other areas of the NHS. Evidence shows that AHPs and nurses in partnerships spend a greater proportion of their time in direct patient care than in other NHS settings, and labour costs are significantly lower than in other NHS sectors. The latter may not be something to celebrate, but it’s a fact.

The partnership model works well, and the creation of an alternative NHS salaried model would dramatically increase costs and reduce capacity. I’m not sure what benefits this increased cost and reduction in capacity would bring – except for an ability for system leaders to feel that they have more control. We would question whether this is the position within the secondary care organisational model.

If we are serious about tackling the workforce issues, many of the best practices for access (and outcomes) are small and fiercely independent, wanting to hang onto a model of family practice. We haven’t produced a valid argument as to why this model shouldn’t be promoted, except that we recognise that the workforce crisis has made these practices less resilient to a key retirement. Our patients may argue that ensuring that we have enough GPs and nurses would enable the maintenance of the model of service that they love.

In summary, Policy Exchange’s report gives us some interesting proposals, but mustn’t distract us from addressing the key problems – that expenditure on the NHS has fallen well below the average in the developed world, and the critical shortage of doctors and nurses. We need to reform the way that we work, including via digital adoption, but do this in conjunction with growing our workforce rather than instead of. The partnership model/independent contractor status has stayed resilient for 100 years – which is a good value of money, and needs to be further supported.

Dr Chandra Kanneganti is GP partner in Stoke-On-Trent and LMC secretary at North Staffordshire LMC, and a Conservative Party councillor in Stoke

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Darren Tymens 9 March, 2022 9:56 am

the question is whether
– this is unmasking an existing NHSE plot, or
– likely to drive a change in direction of government policy.

I think we should take it seriously (as these people have a history of driving right-wing policy initiatives such as Toby Young’s Free Schools).

The target audience is Tory MPs and the right-wing press and its readership.

Interestingly, it is intellectually and ideologically incoherent. The Policy Exchange is a right-wing ‘think tank’ that generally promotes market-based, small business solutions. General Practice should be an absolute exemplar of their principles, running small business and delivering a high quality consumer-centred service at levels of efficiency unmatched in the wider, state-run NHS. It has always confused me that the Tories hate us and want to nationalise us and Labour likes us (or at least hates us less) and wants to keep us as small businesses.

Any objective person would surely look at the evidence for and against this approach and conclude that not only does it not solve any of the current problems, but that it would be a disaster (clinically and financially) to move us to to a salaried model – and that the disaster would be irreversible as we all flee the NHS and offer a higher quality, personalised service.

I think GPDF/BMA/GPC needs its own ‘think tank’ in order to use the widely-available and strong evidence base to rebut these claims. The paper is full of ideology and not evidence – rebuttal should be straightforward and might even move the debate on positively in favour of small business, autonomous, patient-centred, community based general practice .