Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: The new GP contract doesn’t deliver

BMJ 2023; 380 doi: (Published 14 March 2023) Cite this as: BMJ 2023;380:p590
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

“We are drowning, and you throw bricks at us.” This was just one of the despairing responses to the latest general practice contract, published in outline by NHS England on 6 March.12

With a growing population and record numbers waiting for hospital treatment, demand for GP appointments has increased markedly, while the number of qualified GPs has fallen. The new contract information acknowledges that 11% more appointments were delivered in January 2023 than in January 2020, but it fails to mention that this was done with 842 fewer full time equivalent qualified GPs.3

Practices are struggling not only with falling numbers of doctors but also with rising costs and wage bills. Those negotiating on our behalf have asked for help in the form of reduced box ticking and bureaucracy, financial support for energy bills, and help in retaining doctors.4 The new contract doesn’t deliver on any of these counts.

I looked up various definitions of “contract,” and in the hands of NHS England the meaning seems to have shifted from “an agreement” to “an imposed set of instructions.” One of the essential elements of a legally binding contract appears to have gone missing: that of “acceptance of an offer.”5 Perhaps somewhere in the past we all signed some forgotten statement along the lines of: “NHS England is free to adjust the contract in any way it likes and we will meekly submit, however ridiculous the ask.”

The stated aim of this new contract is to improve access to primary care. Yet it’s hard to work out from the information circulated so far what exactly we’re expected to do, how this will be measured, and what kind of sanctions (presumably financial) will be imposed when we fail. It says that “patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice.” But what does this mean? That every time a receptionist answers the phone they must do a full triage of the clinical problem? If so, we’ll need a greatly increased number of highly trained reception staff. Some GPs are already suggesting that we will inevitably, collectively, be in breach of contract, as it won’t be possible to deliver what’s being demanded of us. Perhaps it was never intended to be workable and is just more political messaging from the government, another populist stick with which to beat GPs.

If the intention really is to improve patient access, the effect is sadly likely to be the opposite. Encountering bricks when we asked for a lifebelt will be the final straw for many GPs, leading to yet more early retirements and diverted careers. For those with enough energy left for the struggle, industrial action becomes more likely. This decision is difficult for all doctors but particularly complicated for GP partners. Aside from our self-employed status, we feel a personal obligation to the patients we know and care for.6 We could just stop our non-clinical work—but if all we refuse to do is tick the boxes, engage with the Care Quality Commission, and attend our appraisals, will anyone notice?