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A tectonic shift in general practice

There is an earthquake coming. 

The tremors are being felt as CCGs prepare to take over large swathes of primary care budgets, carving up the national GP contract and using the funding to finance local schemes.

GP practices in Somerset have led the way, opting out of the QOF en masse, but retaining the funding by signing up to a local contract that has a completely new set of goals.

And Somerset could be just the first of many areas to take this route.

CCG leaders around the country have responded to NHS England’s call for ideas on how to move forward with ‘co-commissioning’ GP services with area teams.Their plans were submitted at the end of last month, with some proposing they plough QOF and DES funding into a local contract and others considering shifting practices wholesale onto APMS contracts.

These radical plans are the only way that primary care planning can be ‘clinically led’, claims NHS England’s head of primary care commissioning Dr David Geddes in our Big Interview this month. But he faces massive opposition from the BMA, which says undermining the national GP contract would be an ‘absolute, unmitigated disaster’.

This opposition is to be expected – the BMA faces becoming an irrelevance if large sections of the contract are devolved down a to local level – but its argument that the plans will fragment care and remove the protection of a national contract from practices does have some truth in it.

There is also an increased risk of CCGs being accused of conflicts of interest when awarding contracts to ‘their own’ and the plans would also change entirely the nature of CCGs, which were sold as being owned by their representative practices. In reality, this has never been the case, but it would become nigh-on impossible if they were increasingly involved in the monitoring and performance-management of practices – the obvious endpoint to what NHS England is proposing.

Having said that, the LMC leaders I have spoken to recently seem reluctant to brand co-commissioning as wholly bad.

They see the potential for working locally with CCGs to channel funding into primary care. Anything must be preferable to dealing with shrunken and chaotic NHS England local area teams, and they can see the potential to win resources to develop crumbling GP premises and restore comprehensive community services to support GPs.

Many GPs regard the 2004 GP contract as a long-running disaster for the profession, and think that they have been let down by the GPC and its negotiators. It is understandable if they feel they have little to lose by trying to negotiate better funding locally with CCG leaders that they know. They are disillusioned following year after year of funding freezes or below-inflation pay rises. Why continue under the yoke of the national contract if you cannot even afford to pay yourself?

It is these strong, polarised views over co-commissioning that make it potentially the most dangerous plan NHS England has come up with to date. It could become a major fault-line that splits general practice completely in two.

Nigel Praities is the editor of Pulse.