The short term crisis in A&E and the long term need to move care out of hospitals are two pressures facing primary care. Photograph: David Levene for the GuardianPrimary care is about to be seized by a degree of turbulence and change that will make the acute sector look ordered and calm.
The pressures for change are coming from every direction: the short-term crisis in A&E, the long-term need to move care out of hospitals, the need to improve access to GPs while reducing their workload, the tightening economics of general practice and the need to improve clinical quality.
Looming over all this is the determination of Jeremy Hunt, the health secretary, to claim the government has "sorted out primary care". His speech to the King's Fund last week made plain his game: having decided that the Labour's 2004 GP contract is the source of problems ranging from poor care of older people to A&E pressures, he is going to rewrite it by next April, sweeping away bureaucracy and securing a "dramatic simplification" of targets and incentives.
The demands for higher clinical standards and a wider range of community services are combining with the need for GPs to cut costs to eradicate singlehanded practices slowly. While GP federations and networks are growing, others are taking a more radical approach.
The Vitality Partnership in Birmingham, one of the models debated at the King's Fund primary care conference, is standardising procedures, has clinical peer review backed up by its own turnaround team, runs an effective patient records system which is gradually reaching local hospitals and has centralised, low-cost administration. It is now a major provider of services such as rheumatology and dermatology.
GP culture can often present itself as conservative, suspicious, even cynical, but the reaction of groups such as Vitality to the threats and opportunities shows the passionate and entrepreneurial side of primary care. It is also striking how leading players are not waiting for the local area team or clinical commissioning group to tell them what to do; they are leading change themselves.
These organisations are a long way from the public's traditional perceptions of the family doctor. They are increasingly large, multidisciplinary teams with efficient, benchmarked systems run across several sites. Against this background, the independent contractor model for general practice looks archaic. Professor Clare Gerada – soon to begin her part-time role for NHS England as clinical chair for primary care transformation in London – is already preparing us for its demise.
On top of all this, everyone, from NHS England to clinical commissioning groups, now recognises that shunting primary care commissioning to NHS England's local area teams was a bad idea. It will fail to align primary services with the groups' wider goals and it will not deal effectively with substandard doctors.
Involving groups in primary commissioning means solving the issue of GP commissioners facing a conflict of interest. One solution could be for councils' health and wellbeing boards to play a role in awarding primary care contracts, such as overseeing the governance.
With all this change, it is difficult to see how the GP workload is going to fall. The widely claimed 14-hour days are simply unsafe. As the Care Quality Commission's new chief inspector for primary care, professor Steve Field, begins work, there is a risk of GP services becoming the next part of the NHS to be accused of serious failings.
Hunt has promised more primary care funding, and Health Education England has been charged with getting many more GPs into the system, but even the minister admits existing plans may be inadequate. And beneath these national numbers many areas with the worst health are desperately short of GPs.
Overall, significant parts of the primary care system are unsustainable financially and clinically, but elsewhere GPs are building new, integrated care systems in the community which hold out the prospect of reducing emergencies, shifting treatment away from hospitals and improving access. This is a cause for optimism, but it needs more money and more staff. Funding has to be moved from acute to primary care, which means shutting some hospital services.
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