NHS England has just launched a public consultation on the future for GPs.  You may never see any evidence of this consultation since it is securely hidden away in the morass of the DHSC website, and the consultation text is not downloadable as a coherent document.

It’s not clear who it is aimed at. For example the first question asks the reader to weigh up the conflicting views in eight academic papers!

A serious consultation should start from a shared understanding of what the problem is that needs to be solved.

A few things appear to be accepted – that getting an appointment in many areas is far too hard; seeing the preferred (“right”) GP is almost impossible; GP practices need to fit better into a network of other community based services; and that GPs are overwhelmed both by the sheer number of patients but also by the paperwork.

Reality is not so simple.  And lurking in the background is the never-ending critique by some of the “small business” model for GPs, with the majority of GPs preferring a salaried, flexible professional role that is family-friendly.

And just to make it even more complex, do we still want GPs to act as gatekeepers? You can only get into the expensive bits of the NHS if your gatekeeper gives you a referral. Can there be more self-referral even in a system where there are no charges?

Another set of important problems are also relevant, but little discussed.  The geographical distribution of GPs is not determined by needs, and in some places of high deprivation coverage is poor whilst affluent areas have an abundance.

This is not new. Fifty years ago Welsh GP Julian Tudor Hart exposed the ‘Inverse Care Law’ (those in greatest need get least, and those in the best health get most, especially when the market is functioning).

Variations in performance are in excess of what they should be – there are great examples of GP practices and Primary Care Networks that are doing a fantastic job whilst others struggle even to have a functioning appointments system – for no immediately obvious reason.  And the small business model is not so easily scaled up to become an integrated primary/community care provider.

It also needs to be accepted that the whole primary/community care sector is fragmented and so has no voice where decisions are made. The ‘Transforming Community Services’ project from 2005,  which stripped local commissioners (then Primary Care Trusts) of their ability to deliver services, and  put the services out to the market, was a mistake!  The magic of the unseen hand did not happen.

What is obviously necessary (and is there in the Health Boards of Scotland and Wales) is to establish a part of the system that has responsibility and accountability for primary/community care as a whole.

Why not allow ICBs to go beyond commissioning, and own/lease property and employ staff to deliver services?  If an area is short of GPs then the ICB should set something up.  If a practice needs a home, let the ICB provide it and charge an equitable rent.  If extra staff in a GP Practice would be beneficial, let the ICB employ them, so they can work alongside others in the ‘Integrated Care Centre’ or whatever it will be called. Why not ‘Health Centre’?

The alternative is the mess we have today.

In theory gaps in primary care are filled by ‘the market’, but this has not happened in almost 20 years, and in my view won’t: remember Babylon and GP at Hand, and the American companies (UnitedHealth and Centene) who have bought in to and then baled out of GP practices .

Moreover whilst GPs can access funding from a whole plethora of schemes to fund wider activities these funds are temporary and often only available after bidding and other bureaucratic hoops.  Some practices have great IT systems (they do exist) whilst others are lamentably bad: but where do GPs go for support and stable funding to move to better tech?

The whole mess is unstable and why would a GP take on the risks and the burdens for no obvious return?

GPs have financial incentives in abundance, based on the old adage that “to get GPs to respond write the request on a cheque”.  But having 53 priorities, as now, is silly: and anyway much of the evidence suggest financial incentives often do not work as intended and have unintended consequences.

So, where is the sanction for GP practices that don’t perform?  Who steps in, first with help and support but then if necessary with harsher measures? Nobody does.

So how to respond to the consultation?

A few suggestions.  Stop regarding GPs as a homogeneous group and accept there are and will have to be multiple solutions not one imposed top down. The Additional Roles Reimbursement Scheme (ARRS) maps practice needs and signposts expertise available to practices. Deep End practices demonstrate how resources can be mobilised to tackle deprivation, whilst Compassionate Communities focus on relational ways of working.

Get rid of the market and end APMS contracts that can be bought up by companies.  Ensure ICBs are accountable for a proper distribution of appropriate services, with the powers necessary.  Allow ICBs to set up and run services where they are needed without the rigmarole of tendering and competition.

Give primary/community care a strong voice in the governance of ICBs/ICPs to match the clout of the Trusts and Foundation Trusts.  Explore why some places have really good GP services and others don’t – and then encourage some to build on the best through support and if necessary funding for change.

Keep the small business model for those that want it, but allow variations so that property and staff risks can be mitigated, and also allow new types of GP service provision (not APMS) using staff employed by the ICB or even in a few cases by a Trust (or FT).

Encourage co-location and “integrated care centres” with GPs in them: but don’t force a common design model or set some arbitrary deadline, or give them a daft name!

As always it comes down to getting the model right for responsibility and accountability.  Find a way that delivers without a massive top down reorganisation or requiring legislation.


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