As I opened the envelope from the British Medical Association, I found myself reflecting on a tumultuous few months. The envelope in question contained a justification of the GPs' committee's negotiating stance on extended hours and a form for voting on enhanced payments options.
Health secretary Alan Johnson has certainly earned his union negotiating credentials securing a worst and least worst deal in the eyes of the BMA. But then the chips were on his side, as the speed at which the BMA managed to fall out with prime minister Gordon Brown is quite simply incredible.
The drive for NHS reform has become not only urgent with a strategic review but also personal with what can be sensed as a degree of payback for the perceived waste of public funds.
Why am I feeling so reflective when colleagues around me are clearly irate? Well, the truth is that I decided to leave my position as a GP principal and join the management board of the UK's largest trading charity at the end of last year. I certainly never look at a half empty glass, but falling profits, lack of ability to influence reform and looming uncertainty are not principles of winning engagement.
So is almost a century of family-centred, list-capitated, longitudinal gatekeeper primary care about to disappear?
You can sense the mood music from the opening paragraph of the committee's letter: "Please be aware that if you select option A, you are not necessarily endorsing the government's proposals and can still indicate your opposition to both options." The voting form helpfully goes on to ask GPs about their attitude to the government's negotiating tactics.
There is an underlying reason for this: the 2004 general medical services contract was a huge own goal on both sides. The balance between out-of-hours and payment for quality was skewed naively and largely in favour of GPs.
Now I am sure the GPs' committee didn't steal the money any more than NHS employers understood the true cost of out-of-hours provision. The deal breaker surely came when GPs started to fill in their tax returns and pension forms, suggesting politely that little of the added funding had been reinvested in practice services.
The deal in 2004 suited the political needs of the day. The deal in 2008 is clearly different and for GPs has come home to roost. The idea of extended hours and extended services is quite simple providing you don't call them a polyclinic. There is a commitment to deliver 150 of them, all under alternative provider medical services contracts, in this year's operating framework, with 10 proposed as pilots in London alone.
Hospital trusts and independent and third-sector providers are clearly gearing up to play in this arena. It is not unreasonable for GPs to expect to retain general medical services or personal medical services (albeit on slimmer margins), but the new areas of growth are going to be in extended services, such as flexible diagnostics and wider primary services. Business efficiencies will come from leveraging buildings and bulk cost savings from running clinics at scale.
My advice to GPs as a poacher turned gamekeeper is simple: be on the front foot, back some college leadership and find a commercial partner now.