By Martin Hutchinson

General practice wasn't a popular specialism in the past

It adds up to an extra �1.76bn from the public coffers so far, and, according to their report, plenty of this has disappeared into the pockets of GP partners themselves.

Average earnings of the partners who own and run practices have risen by more than half and failed to deliver much for patients, says Edward Leigh MP, the chairman of the Commons committee which oversees the NAO.

"They are being paid far more, are working less hours and their overall productivity has dropped."

The overspend on the contract is not the fault of GPs Dr Laurence Buckman BMA

On the face of it, these figures could be used to paint the relationship between GPs and the public purse as an almost entirely mercenary one, with our family doctors taking full advantage of a loosely thought-out agreement.

But there are many in and around primary care prepared to mount a robust defence.

GPs have historically enjoyed an unique relationship with the NHS, forming a well-drilled army of small businessmen at the very heart of public service in the UK.

In the run-up to contract negotiations in 2003, it was generally agreed that they were some of the hardest-working professionals in the health service - and that there just weren't enough of them.

At the time, only 20% of doctors wanted to be GPs, with the dubious attraction of long hours - including evening and weekend work, plus relatively poor pay compared with the hospital sector.

Primary target

At the same time, primary care was seen by ministers as a key target for some of the modernising billions aimed at the NHS, with the intention of keeping people with diabetes and asthma, and others with long-term conditions out of hospital and perhaps even off benefits.

Even so, the British Medical Association was not ready for the apparent generosity of the government.

Negotiator Dr Simon Fradd said it was "just stunning" when the Department of Health offered GPs the chance to abandon out-of-hours working altogether for just a 6% pay cut.

The new incentive scheme also offered the chance for practices meeting basic standards of care to draw in much greater sums of cash.

The central problem for ministers appears to be that, if anything, GPs were far more efficient than they predicted, meeting all the targets swiftly in a financial system which relied on this taking a few years more.

Whether or not meeting those targets has delivered many actual health benefits to patients is still unclear.

It's how efficient you are at work, not how many hours you work Professor Mike Dixon NHS Alliance

The BMA's Dr Laurence Buckman said: "The overspend on the contract is not the fault of GPs - the BMA repeatedly told the government that GPs would exceed the targets they had set them."

The new contract certainly eased the recruitment crisis, with thousands more doctors now lured to general practice. In many areas now, there is fierce competition for GP posts.

As a result, there are more GPs, and more consultations with patients, but each GP is carrying out fewer of these, and NAO says this means they are less productive.

Mike Dixon, from the NHS Alliance, said this was a "pretty dubious" argument.

"It's how efficient you are at work, not how many hours you work."

Salary cap

One of the criticisms from the NAO was that negotiators did not try to limit how much of the additional money for practices could be taken as increased pay by GP partners.

Former Health Secretary Patricia Hewitt has said that, in retrospect, this would have been the right thing to do.

However, Dr Dixon defended GPs: "We have to remember that GP surgeries are businesses - and perhaps one of the reasons we are so efficient is that very fact."

The government has been bruised by all this, and is looking to claw back ground at every opportunity Professor Martin Marshall The Health Foundation

He said that there was no doubt that some doctors were driven by money - but that did not make them bad doctors at all.

Another key to the success of the contract was the ability of primary care trusts to force through other improvements, including better opening hours for patients.

Professor Martin Marshall, from the Health Foundation, an independent think-tank, said that it had been unrealistic to expect this.

"I think there simply was not the capability or capacity in PCTs to drive this forward - unfortunately, those running them are not always of the best quality compared with those in hospital trusts."

Now, he says, the government is struggling to recover lost ground, and relations with the BMA, normally tetchy, have been particularly fraught recently over a proposal for GPs to work an average of three hours a week longer.

Professor Marshall said: "The government has been bruised by all this, and is looking to claw back ground at every opportunity."

However, the fiercely-guarded independence of GPs means that reform must always come with the agreement of the profession, which could mean many more difficult trips to the negotiating table.