A week on, GPs are still struggling to make sense of the series of bombshell announcements about the future of the contract last Tuesday.
First, we were told the Government was offering a 1.5% practice funding uplift next year. Then it emerged the unusual announcement had been prompted by a breakdown in talks with the GPC. Then we found out that up to a quarter of the QOF would be retired under the DH proposals, with a hike in indicator thresholds and new enhanced services for dementia care and online access.
And then it got even bigger. MPIG to be phased out over a period of seven years. Adjustments to the Carr-Hill formula. A move for all practices towards a ‘common capitation price’. Ambiguous, ominous talk of ‘a consistent and equitable approach in relation to PMS agreements’. All far-reaching developments which between them could herald a seismic shift in the balance of general practice funding.
Quite what the combined effect of so many massively complex changes will be on individual practices is an open, and pressing, question. The BMA, although initially involved in discussions around the phasing out of the MPIG, has warned the deal as a whole will be ‘bad for doctors, bad for patients and bad for general practice'. Not everyone will share that view – the correction factor is a hugely divisive issue, and many GPs believe the end of the MPIG is long overdue. But either way, accountants are furiously crunching the numbers to try and assess the impact – although with so many different variables it’s a Herculean task.
But while there continues to be considerable confusion over the Byzantine details of the changes and their likely impact, the politics of last week’s developments are much simpler.
At the NAPC conference in Birmingham yesterday health minister Earl Howe claimed that the Government is keen to get the BMA on board – but also warned it ‘won’t back away from making changes that will deliver better care for patients’.
The formal consultation required before the Department of Health can unilaterally impose the changes has already technically begun, and the Statement of Financial Entitlements is due to be published in mid-November if no agreement is reached before then. In fact, it gets worse – the DH has also said that if no agreement is reached it will consider evidence from the Doctors' and Dentists’ Remuneration Body on funding uplift, which it may or may not accept – raising the prospect that even the small carrot of a 1.5% uplift could be removed while the big stick is imposed all the same.
If all this sounds a little familiar, then it’s because we’ve been here before with extended hours. Then, as now, the Government insisted GPs sign up to a series of unilateral demands - and threatened to impose an even worse set of unilateral demands if they failed to do so.
It’s a gambit which back in early 2008 brutally exposed the limitations of the negotiating process and left the GPC fuming, but largely impotent. As a cub reporter on Pulse I wrote up the story for our front page, which warned somewhat presciently that an MPIG imposition could be next - and negotiator Dr Peter Holden as ever summed up the situation perfectly.
‘The Government is bullying us because it knows we can’t do anything, as we either hurt patients or commit suicide,’ he told me. ‘The Government can dictate its price – I see nothing but blood, sweat and tears.’
There are three key differences with the situation in 2008 though – differences which will shape the next few crucial weeks and may determine the outcome of the dispute.
Firstly, and obviously, this is much, much bigger than extended hours. GPs were outraged at being forced to work evening and weekends to maintain their income – but the workload implications of the proposed changes for next year are much bigger, and the financial implications of the longer-term plans for the end of the MPIG could make or break practices. The current dispute is more 2004 than 2008 – for GP funding, the stakes really could not be much higher.
Secondly, the disastrous attempt at and swift retreat from industrial action over pensions earlier this year is the elephant in the room. Ministers only felt emboldened to suggest – let alone demand – such far-reaching changes because they were confident the BMA is in no position to do much about it. Fighting to defend practice funding at a time of national austerity was always going to be a big ask; the pensions’ defeat may make it impossible.
And thirdly? As ever, the NHS reforms are the joker in the pack. There is no little irony in ministers picking a fight with GPs a matter of months before they hand them unprecedented commissioning responsibility. That they are willing to do so suggests they feel the profession is already on board as much as it needs to be, and that the momentum behind commissioning is irresistible. Certainly so far at every turn the BMA has furiously resisted calls for it to lead some kind of commissioning boycott.
But in the closing paragraph of his furious two-page letter to the profession in the wake of last week’s announcement, GPC chair Dr Laurence Buckman picked his words carefully.
‘All practices are going to need to look carefully at the way they work and prioritise their commitments to protect core patient care,’ he wrote. ‘I am sure you will share our dismay that the Government has failed to recognise the difficulty GPs will have engaging fully in new CCG work whilst managing these huge contractual changes.’
A parting complaint about workload? Or a coded threat about something more? Right now, it’s impossible to tell – and the GPC won’t say. The future of GP funding might just depend upon the answer.
Steve Nowottny is the editor of Pulse. You can follow him on Twitter at @stevenowottny.