Think tanks and so-called policy experts have left the capital awash with ideas for NHS reform, says Londonwide LMCs chief executive Dr Michelle Drage, but support for 'change at the point of delivery' has been minimal.
Within weeks of Londonwide LMCs launching its report, Securing the Future of General Practice, last September, NHS England's London team launched its own document, Transforming primary care in London: general practice - a call to action.
The forces for change, on all sides, are focused on the capital's primary care services. But Dr Drage dismisses 'airy fairy' talk of transformation from think tanks and policy experts as likely to achieve little more than perpetuating uncertainty.
In contrast, the capital's top GP says a further report, due from Londonwide LMCs as GP goes to press, is about GPs 'doing things for ourselves', from the 'bottom up', and not relying on 'the system'.
Dr Drage talks a lot about 'the system', as a kind of external force in opposition to GPs on the ground. Londonwide's second report, Meeting the Challenge, and an accompanying conference, aim to draw on core elements of the first and begin to describe what GPs can do to reshape services around the needs of general practice and patients.
The report focuses on workforce, premises and infrastructure, quality, access and developing providers.
In a meeting room at Londonwide LMCs' office overlooking the courtyard of BMA House, Dr Drage says: 'Nobody is enabling change at the point of delivery. That's where the support isn't: on the ground.
'You can have all the strategic ideas under the sun. But actually the solution is to take some cash, not huge amounts, and refocus the service on provision of general practice.'
What is so special about the capital that demands its own strategy for general practice? Dr Drage reels off a list: 'Turnover, deprivation, health inequalities, expectations and the most complex boundary issues and territory issues.'
Whereas other parts of England may have a single local hospital, a single local council, perhaps even a single GP practice, in London, she explains, 'there is nowhere where you don't have at least two providers, two local authorities to deal with, and they may not coincide with your community services'.
On top of that there has been a 'total disinvestment' over 15 years in community and support services, which general practice relies on.
General practice, she says, like the Tube system beneath the capital, is creaking. Londonwide's first report called for a doubling of the 8% share of funding that London primary care receives, from £1.2bn to £2.4bn a year. Dr Drage now says it should be trebled.
Her strategy is about showing GPs how to organise together, in spite of 'the system', to shape commissioning around general practice. The commissioning system, she says, 'doesn't work' for general practice, and is 'dominated by the need to feed the beast of our major teaching hospitals'.
Londonwide wants to convince GPs on the ground to collaborate, to 'create facts on the ground', to demonstrate the case for commissioners to begin shifting resources from hospitals to the community.
Dr Drage rejects the term 'federations', favoured by the RCGP and NHS England, because it means different things to different players.
Instead she talks of collaboration, which she says is a very basic idea.
'What it can mean,' she explains, 'is two or three practices near each other saying: "Let's look at local population needs and, maintaining our autonomy, how we deliver services. How could the population's needs be better met? Could we agree to share expertise, and use that platform to encourage our CCG to commission more community services around that group of practices?".'
With the economies of scale that collaboration brings, practices can make better use of resources. It could also protect small practices against pressure to 'scale up', she adds.
Londonwide's task, Dr Drage believes, is not only to convince commissioners to shift funding towards GPs, but to convince her 'tired, overworked, demotivated, demoralised' colleagues of the case for reshaping from below. CCGs should have done more by now to build community nursing, links with social care and access to diagnostics, she argues.
'If they'd shifted 5% of resources into community services and enabled those to support general practice, they would probably have made a 20% impact on general practice.'
For London, Dr Drage says, what primary care really needs is a 'return to the initiatives of the 1990s', when, she says, the city was last treated as a coherent whole.
Special contractual arrangements enabled fast development, with small amounts of investment in education and training helping London to lead the country with clinical collaboration on diabetes and asthma, golden hellos to boost recruitment and a collaborative working allowance.
'That's what London needs to come out of the changes. They could be contractual - that's not changing the national contract, that's making better use of resources and having a contractual arrangement around those. I would be the first person in there negotiating for GPs.'