GPs responding to the publication of NHS England's GP Forward View could be forgiven a bit of cynicism. The coalition government's promise of 'no top-down reorganisation' of the health service resulted in an overhaul described by former NHS chief executive David Nicholson as so big you could see it from space.
Meanwhile, plans to recruit 5,000 new GPs look unlikely to materialise, the case for a seven-day NHS is based on flawed evidence and junior doctors - set to vote soon on whether to accept a new contract - were forced into unprecedented strike action.
Trying not to be cynical, GPs could take the stance that the GP Forward View has to be seen as a step forward. It tries to respond to key issues raised by general practice. It takes a broader view than just the GP. It spends time on IT. It takes tentative steps towards the issue of indemnity. It helps with issues of premises. And it provides significant funding.
Unfortunately, a look at the bigger picture throws much of this in doubt. NHS chief executive Simon Stevens returned to the UK from a huge US health organisation and might be expected to boost privatisation in the UK. A cynic might wonder if that is why he was brought back.
In some ways, though, his actions in post have been to find as many ways as possible to avoid the chaos of the Tory redisorganisation embodied by the Health and Social Care Act. Sustainability and transformation plans (STPs), working more closely with local authorities, the Five-year forward view, all pull the NHS away from competition and marketisation.
But the legal procurement infrastructure, now boosted by new laws from the EU, makes it very difficult to avoid putting services out to tender as part of the commissioning process. So, all these new structures: new models of care, STPs, devolution and some of the recommendations in the GP Forward View will inevitably lead to more entries for the private sector into clinical care and commissioning.
Despite the promise of at least a £2.4bn rise in GP funding by 2020/21, a number of key questions remain.
The RCGP suggests the money will be a mix of funding from the Estates and Technology Transformation Fund (formerly the Transformation Fund), a 10% uplift in CCG spending, a new sustainability and transformation package and the Better Care Fund.
But Londonwide LMCs has warned that £2.4bn would leave general practice below 2010 levels of funding. Surgeries need money now, and CCGs will find a 10% levy very difficult to manage, even if it is for our own tribe.
There are also concerns about from whom the money is being stolen to top up primary care. Some, I understand, could come from pharmacy and some presumably from social care via the Better Care Fund. Meanwhile, polling by the Healthcare Financial Management Association has found that CCGs and mental health organisations say promised uplifts in mental health funding have not materialised - so why should this be any safer?
Critics such as GP Dr Margaret McCartney have challenged many of the assumptions in the GPFV. Writing in the BMJ, she argued that sadly, like much of the NHS’s plans, many of the recommendations are evidence-free and have more than a whiff of magical thinking about them.
GP industrial action
And ultimately, we are bleeding right now - surgeries are shutting. The NHS workforce is inadequate and planning is chaotic, the House of Commons health select committee has warned. Social care cuts are leaving patients in dire straits.
GP recruitment is under strain everywhere (except my surgery actually, where we are now, for the first time in years, up to full strength!). Sadly, the GP Forward View does not give the support needed right now. It avoids the issue of indemnity which would have made a rapid difference. The government has pledged to create 5,000 new GPs by 2020. Again, most of general practice knows this is never going to happen.
Parts of the plan around linking with other sectors, such as pharmacists, are good. Different additional workers may be useful, though their effectiveness is largely unproven. But we need a grander vision for primary care to include those sectors that have perhaps as much impact on health as we do: housing, for instance. The housing sector has developed radical approaches to health issues and we should be working more closely with it. We need incentives and support to make that possible.
We need a contract that explores whether the small business model of general practice is really fit for purpose, whether in federations or not.
There is little, too, about working with the communities we serve. This remains a major blind spot for the NHS, despite attempts by some vanguards to explore evidence-based options such as community development. This can improve health protection, support individual behaviour change, help statutory organisations be more responsive, help tackle health inequalities – and may save money, too. The GP Forward View missed an opportunity here.
It remains to be seen whether NHS England and Simon Stevens have done enough to keep the threat of GP industrial action at bay. GPs at the LMCs conference last month voted for a ballot on industrial action or mass resignation in three months' time if the government fails to adopt steps set out in the BMA's Urgent prescription for general practice.
In my view, GPs should protest formally and take industrial action – not only for our sakes, but for the sake of the NHS. We need to show that this offer from the government is too little, too late. That we do not trust this offer which is on the backs of other sectors in the NHS. That the government’s austerity is destroying the lives of citizens and the NHS. That we understand how the junior doctors have been mistreated and we stand by them.
This is not cynicism – this is a call to action.
- Dr Brian Fisher is a GP in Lewisham, east London, and honorary vice president of the Socialist Health Association.
Photo: Dan Wootton