London's 5,000-plus GPs now know they could be for the chop.
Under commission from NHS London, the professor of surgery at Imperial College has come up with a plan for the capital's future healthcare.
Professor Sir Ara Darzi's plan, out last week, was widely trailed as recommending a network of 'one-stop shop' supersurgeries, each housing around 25 GPs and catering for 50,000 patients.
The supersurgeries will be expected to provide access to GPs during extended hours and to offer out-of-hours services as well as community and specialist services, south London GP Dr Ian Harper told last month's conference of LMCs.
Meanwhile, Sir Ara has been appointed junior health minister.
Liverpool is also expected to go down the supersurgery route. And so did Warrington, almost.
There was shock among the 120 local GPs in 29 surgeries when Warrington PCT announced in February its primary care strategy.
'What it wanted to do was to close every practice in Warrington and replace them with five supersurgeries which would be open from 6am until 10pm,' said Runcorn GP Dr Gareth Morgan.
'They would be developed under APMS contracts and all the GPs working in them would be salaried to the APMS provider.'
Warrington PCT went through the required three-month public consultation, issuing a 'bland document, motherhood and apple pie stuff' that was posted in surgeries and public libraries but not sent to patients' homes, he said.
'Patients were hopefully going to be led by the hand.'
Before Christmas the PCT had served notice on a number of PMS GPs, only to revoke the notice following protests.
Now incensed again, Warrington's GPs closed ranks. They saw that to win this battle they needed to win public opinion.
They posted notices in their surgeries explaining the implications of the polyclinic strategy: patients could lose their GP, the very patients who most valued continuity of care could lose it and to visit their doctor they would now have to travel.
'We do not believe that without us our patients would have been properly informed,' said Dr Max Levy, Warrington lead on Mid Mersey LMC.
The GPs told Warrington PCT what they thought of the strategy in a joint letter expressing their 'disappointment'.
Fifteen surgeries circulated 24 petitions protesting against the plan.
The GPs spoke to the press and contacted their MPs. They spoke out at the PCT's public meetings.
'We lit the blue touch paper and stepped back,' said Dr Morgan.
Numbers at the public meetings escalated to more than 400. Some 21,314 patients signed the petitions. The PCT extended its consultation period.
By June the consultation showed that the public voted four-to-one against the 'health supermarkets', which were to be indefinitely shelved.
Warrington's GPs learned three lessons from the victorious encounter, said Dr Morgan.
'First, there may well be a hidden national agenda for supersurgeries. Second, acting together is strong. 'If you all get together you achieve things as GPs.
'Third, our biggest asset is our patients. Without them we wouldn't be where we currently are.'
Jan Holding, head of partnerships at Warrington PCT, did not accept that the protests were the reason for its turnaround.
'We were talking about centralising GPs and about changing their contractual status. It was the contractual stuff that blew it out of the water,' she said.
She is clear that supersurgeries and a change in contractual status is the national direction of travel.
'GPs are waking up to the fact that it's not a monopoly situation any more. I am interested to see what goes on nationally,' she said.
In developing their case, GPs accept a limited role for supersurgeries.
'Supersurgeries already exist in some areas,' said Dr Harper.
But they argue they are 'predicated on an unproven logic followed in different countries to our country' and lack an evidence base.
Furthermore, said Dr Harper, 'the financing of them and their size are clearly attractive vehicles for privatisation and ideal models for vertical integration by grasping foundation trusts.'
Any advantages of joint working implied by polyclinics are already available under practice-based commissioning.
GPs nationwide have been handed a proven model of how to protest by their Warrington colleagues. They may need it.
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