Just as GPs' first pay rise in four years starts to trickle through, a new era of NHS austerity has reared its head.
GP leaders warn it will be a lottery how PCTs react to massive funding gaps, which the NHS Confederation predicts will hit £15 billion by 2016. Many, GPs fear, will raid primary care budgets to make ends meet.
The shortfall predicted by the NHS Confederation this month dwarfs the last NHS funding crisis in 2007, when trusts amassed debts approaching £1 billion.
If investment growth is not sustained, with our increasingly obese and ageing population, the NHS could find itself £8 billion to £10 billion short by 2014, rising to £15 billion by 2016.
New health secretary Andy Burnham remains adamant 'it is not a crisis' and political parties have made reassuring noises about protecting the NHS from public service cuts.
But NHS chief executive David Nicholson has told managers to plan for cuts of 2.5-3 per cent from this year.
The DoH hopes to save £500 million annually from reduced stays in hospital and another £500 million through 'improved commissioning and processes'.
But senior figures at the NHS Confederation conference in Liverpool this month felt that before continuing to invest in community services and cutting hospital demand, savings could be made in general practice.
QOF income could be among the first targets, NHS Confederation policy director Nigel Edwards suggested, and contracts will be reviewed in the hope of expanding core work.
Contracts could be altered to make what were once additional services minimum standards, said Chris Ham, professor of health policy at the University of Birmingham.
Managers have even considered charging patients for appointments in the hope of keeping demand down, said PCT Network director David Stout. Policy-makers will also look at GPs working as part of 'managed organisations', rather than as independent contractors, if all else fails, said Mr Stout.
It depends on the PCT, according to NHS Alliance chairman Dr Michael Dixon. He fears less competent PCTs will abandon redesigning services and start cutting jobs and budgets.
'Some will be constructive, some will take the old-fashioned approach. The latter will say "no" to everything, cut services and people, hold back on training and introduce draconian referral management centres.
'The better scenario is that PCTs recognise GPs are their best asset in times of a downturn. Part of their role will be limiting care where it is not necessary, but a lot of it will be redesigning services. Anything to keep patients out of hospital and help themselves,' he says.
NAPC chairman Dr James Kingsland admits he is 'frightened' by the way managers have reacted this month.
'I hope we do not see a style of management like two years ago when we were last in financial difficulty. Raiding primary care contracts will do diddly-squat in the long term,' he said.
The answer to the crisis, Dr Kingsland and Dr Dixon agree, is commitment from both sides to that faithful panacea, PBC.
'If GPs are engaged with commissioning, they will look at both quality and cost. If they are not bothered, no manager can save much. They cannot impose a solution on an alienated profession,' says Dr Dixon.
'We have enough funding in the NHS,' Dr Kingsland adds, 'but it is riddled with duplicated services and tonnes of wasted work.'
GPC deputy chairman Dr Richard Vautrey says practices need more funding. Any cuts should centre on management costs and hospitals, he says.
'The managers' view that you can do more with less resources is not tenable in general practice. Our expenses-to-earnings ratio shows that if you cut back any more, services will suffer.'
The signals suggest GPs may again be on a collision course with managers and the DoH.
Interestingly, GPC chairman Dr Laurence Buckman extended an olive branch to the DoH at the LMC conference this month, calling on ministers to work with, not against the profession.
This was sensible, says Dr Kingsland, and could help GPs ride out this storm. He adds that GPs can no longer refuse to engage. 'Saying "it'll be all right in the end, let's wait for the next government to come along", is not going to work this time.'
Views on NHS funding cuts
- NHS managers should plan for cuts to be made to NHS funding of 2.5-3 per cent from this year. Political parties are offering growth, but let's not kid ourselves.' David Nicholson, NHS chief executive
- PCTs should recognise GPs are their best asset in a downturn. Part of their role will be limiting care where it is not necessary but a lot of it will be redesigning services.' Dr Michael Dixon, NHS Alliance chairman
- I hope we do not see a style of management like two years ago when we were last in financial difficulty. Raiding primary care contracts will do diddly-squat in the long term.' Dr James Kingsland, NAPC chairman
- The managers' view that you can do more with less resources is not tenable. Our expenses-to-earnings ratio shows that if you cut back any more, services will suffer.' Dr Richard Vautrey, GPC deputy chairman.