Nuclear weapons are built never to be used. They sit in submarines, bunkers and lorries, costing billions, for one purpose: to stop anyone else attacking. Their existence changes behaviour at the negotiating table. Everyone knows there is a line that cannot be crossed.

What has general practice got that stops government crossing the line?

Right now, very little.

Who actually negotiates for us?

The BMA’s General Practitioners Committee (GPC) is the body that negotiates the national GP contract with government. It has been doing so since the birth of the NHS.

On paper, this sounds reassuring. The law even bakes in a role for a representative body. Section 87(4) of the NHS Act 2006 says that before the Secretary of State issues directions on remuneration, they:

“must consult any body appearing to him to be representative of persons to whose remuneration the direction would relate…”

The key word here is consult.

Consultation means giving views. It does not mean sharing power. The GPC can argue, warn, explain and plead. Government can listen politely, pick the bits it likes and ignore the rest.

We have already seen this in practice. In recent years contracts have been imposed despite GPC opposition. The BMA did not agree. The profession protested. The contract landed anyway.

The contract you cannot walk away from

GP partners are independent contractors with only one single customer: the NHS.

The core contract is “take it or leave it.” If a practice chooses not to sign, its only source of income disappears. The partners’ business collapses, staff lose their jobs and the partners’ personal assets can be at risk. House, car, savings, the lot.

Historically, there was at least a theoretical soft landing. Practices could manage both an NHS list and a separate private list from the same site. While hardly anyone used this option, it was available. It allowed a practice to plan to withdraw from the NHS by building a private list while continuing to provide NHS services.

That route has been closed. The current contract makes running an NHS list and a private list from the same premises a breach of contract. The message is clear: you can leave if you want, but you will jump without a parachute.

So we have:

A group of self employed small business owners.
A single dominant payer: government.
A contract that can be, and has been, imposed unilaterally.
Personal financial risk if the business fails.
No realistic escape route inside the current system.

It is not a balanced relationship. It is dependency under pressure.

Why I still do not want to leave

For the record: I do not want general practice to walk away from the NHS.

Even if some in government talk as if GPs are outside the NHS, I feel truly ingrained in it. I’m guided by the needs of my patients and not on how much I can bill them for. I never want this to change as it’s an amazing way to practice medicine.

Could we earn more in a private system? Almost certainly. Dentists are the obvious example. However, many are now focusing on upselling whitening and cosmetic work while core life-changing dental care is being squeezed.

I do not want general practice to live in that world.

I want us to stay within a publicly funded NHS, offering comprehensive care based on need. Which is precisely why we need to talk about deterrence.

The missing deterrent

Recent events around online consultations contract changes showed just how weak our position is.

Even where there seemed to be an understanding about how changes would be implemented, government pushed through its own version. The profession raised concerns. The contract still landed. Practices are told to “innovate” their way out of impossible timetables and unfunded workload.

We have no serious deterrent in that room.

If you want a more equal negotiation, there has to be a credible “nuclear option” on our side. Something so serious that both parties are motivated to avoid triggering it. Not a tantrum, not a tweet, not a symbolic protest. A real, thought through alternative path that would change the balance of power.

People discuss undated contract hand-back letters and I understand the anger and share much of the frustration. However, a stack of undated contract hand-back letters without a fallback plan isn’t a deterrent; it’s a bluff and everyone knows it.

For any route that involves saying “no” to a national contract, there has to be:

A transition plan away from NHS income
A workable model for how practices would actually function.
A path that does not simply destroy partners’ finances and leave communities without care.
And most importantly: Clear communication with the public

I do not want that path to end in general practice breaking away from the NHS. But pretending it could never happen is part of why we are so easy to push around.

A deterrent works best when it never has to be used. Yet it still has to exist.

Until then, we stay as the punch bag

Until general practice has built some form of credible alternative, we will stay in our current role:

The easiest group to blame when things break.
The easiest to load with extra work, targets and risk.
With reduced real-terms funding

Without a deterrent, every negotiation is really an announcement. Government decides. We are consulted. The contract arrives. We stretch a bit further to keep something we can still be proud of for our patients.

I do not have the final answer for what our deterrent should be. But I am sure of this: If we want to stay in the NHS as a strong, publicly funded general practice, we need to build an option that proves we could leave. Not because we want to press the button, but to show that we can and that we will if we are not listened to.

Deterrence is not about destroying what we love. It is about protecting it from people who think they can push forever without consequence.

What is General Practice’s nuclear deterrent?

Nuclear weapons are built never to be used. They sit in submarines, bunkers and lorries, costing bil

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