For historical reasons, general practice is split along many lines: sessional versus partner; GMS versus PMS; urban and deprived versus leafy suburbia. Now, though, there is another divide, and one that is currently running much deeper than the others.
The way I see it, there are two tribes are battling over the soul of the profession, and it is a struggle with tremendous consequences for the way GPs will work in the future. The first tribe – let’s call them the ‘reductionists’ – are in the ascendant.
They are the GPs who argue that general practice is full, that its open door is being abused by patients, hospitals and politicians. And this is completely understandable. Efforts to boost access and adjust ‘skill mix’ have been outflanked by the twin foes of chronic underfunding and soaring demand. General practice has reached ‘saturation point’.
Recent Government promises of increased investment of 4-5% a year do little to reverse this. As Pulse has revealed, even in five years’ time, GPs will still receive less than 8% of NHS funding as secondary care continues to suck up resources.
Reductionists look around and sees rising rates of burnout among partners, practices struggling to recruit and young GPs seeking greater job satisfaction as locums. Their solution is to stem the tide of demand by saying ‘no’, refusing unfunded work and reducing the GP role to serve the genuinely vulnerable and sick.
This is the tribe behind the recent LMC vote that backed exploring mass undated resignations if a rescue package is not forthcoming by July. You see their influence in campaigns against the continual redefining of what GPs do, the ongoing drive to burden practices with public health interventions and social work – checking patients’ boilers and the like.
But in the other corner, is a different tribe. I shall call them the ‘expansionists’. They see NHS England’s Five Year Forward View as a blueprint for extending the role of general practice and a chance to build a truly primary care-led health service. They don’t see policymakers as ‘the enemy’ and have little truck with the view that general practice should hunker down and ‘do less’.
They are the GPs that support social prescribing, welcome moves to employ physician associates and pharmacists, and view super-practices providing more specialist and community services as the future. Unlike the reductionists, they have a seat at the table with ministers and they are first in line for extra funding from the health service when it comes. And – let’s face it – they are the ones that are more likely still to be around in five years’ time.
Now tensions can be creative – every ying needs a yang – but I would argue that general practice has to find a way to call a truce and bridge the divide between these two tribes. The reductionists struggle to offer any compelling vision for the future of general practice, whereas the expansionists have no answer to how those outside super-practices can survive in the short to medium term.
And the truth is that in most GPs there is a mix of reductionist and expansionist thinking, but the current climate has tipped many into the reductionist camp. GP leaders now need to find a way to end the tribal conflict so the profession can unite in the battle for its future.
As Frankie Goes to Hollywood put it: ‘When two tribes go to war, one is all that you can score.’
Nigel Praities is editor of Pulse