Big Questions: Next steps in GP contract and same-day access rows

Pulse summarises March’s talking points – where do we go after 99.2% voted against the the 2024/25 contract changes, and why same-day access hubs are not dead in the water yet

What’s actually next in the post-referendum world?

The BMA referendum loomed over GPs throughout March with a whole 20 days to vote whether or not members accepted the Government and NHS England’s contract changes for 2024/25. Unsurprisingly, 99% of the 19,000 respondents voted ‘no’ to the question ‘Do you accept the 2024/25 GMS contract for general practice from Government and NHS England?’ 

So what next then? The referendum was not a formal trade union ballot and instead was described as a ‘temperature check’ of the profession. Equally, the contract was already imposed by the Government at the time of voting, and NHS England had called its changes ‘final.’ The ‘no’ outcome will have no immediate bearing on this decision. 

But what happens instead? At the beginning of March, the BMA put out a tentative timeline for GP collective action, which would be dependent on referendum results. To actually get to the point of collective action, there are still several hoops to jump through. Those hoops include GPC England requesting permission from BMA UK Council to strike; looking at the outcomes of the Doctors and Dentists Remuneration Board in July; as well as then potentially having to hold a ballot on industrial action, likely in September. 

Although there is a long way to go, the strength of feeling among GPs suggests there may be some appetite for industrial action in the autumn. The form this might take is uncertain and will depend on talks with the BMA UK Council in July. 

Striking by its nature is always against an employer. But this dispute is not between staff and an employer, it is between a commissioner (NHS England) and contract holders (GP practices), which makes this a bit murky. 

There are other options: offering private services only; prescribing brand name drugs over generic to cost the Government more money; resignations en masse; seeing only the BMA recommended number of 25 patients a day; refusing to refer patients to secondary care; or a blanket closing of doors on all patients. All of these have problems, however – either they will cost practices a lot of money, as they have to pay running costs without funding, or they will have little effect on patients.  

Added to the mix is the volatile political environment. The original timeline marks October as the announcement of GP collective action, with said action then happening in November and December. This is timed to be alongside the likely announcement of the general election. Once the GE is announced, then we will ultimately have a six-week government silence with ‘purdah’ meaning that no new or controversial policies/initiatives can be announced lest it unfairly influence the vote. In more local terms, this means that both NHS England and the DHSC will be effectively mute.

More importantly, it would also make GP collective action – in whatever form it takes – a doorstep issue for all parties in their pre-election campaigning. The general public will never turn down an opportunity to discuss general practice at the best of times, and if services are reduced in any capacity in the run up to election, you can safely bet it will be in the top three issues they bring to MPs who come to their door.

In addition, there is the possibility of striking in conjunction with other medics, which could draw more attention. Junior doctors have voted to continue strike action until their mandate ends in mid-September. Last October, consultants striked alongside them in their longest period of industrial action yet. GP collective action at the same time as JDs could produce feverish levels of attention, pushing the issue to the forefront of public consciousness. But considering that consultants rejected the offer and are open to further action again this year, suggests that GPs coinciding collective action with JDs could be futile. 

Are same-day access hubs dead in the water?

In February, North West London ICS tried to introduce a revolution to general practice on the sly. Same-day access hubs were essentially mandated in North West London, leaving GP practices to deal with only routine care. The ICS said that practices would have to sign up to the services in order to access funding as part of its ‘single offer’ local enhanced service. Failure to sign up would remove funding they had relied upon.

Under the plans, PCNs would join forces to serve as a ‘single point of triage for same-day, low complexity’ demand for all patients in the ICS. These hubs would have been staffed by one senior supervising GP, managing a team of ARRS staff from practices – for example (as provided by NWL ICB) prescribing ANPs, a social prescriber and a pharmacist. 

There were a number of problems with such a plan. It would have destroyed what is left of continuity of care. It would have left patients having to travel further. And it would have left GPs dealing with only routine care, removing the very variation in work that may have attracted them to the profession in the first place.

But following protests led by patients and practices, and the wider national media picking up on Pulse’s original story, the ICB has backtracked.

The letter sent to practices cited discussions with the LMC, GP practices and residents as instrumental in their decision, emphasising ‘the pressure felt by many practices.’ The ICB noted that its proposals had been ‘misinterpreted.’ The lack of enthusiasm and collaboration towards the programme most likely made it seem an altogether uninviting prospect for the ICB to move forward with this year. But this doesn’t mean that it’s dead in the water. 

Having done away with the idea for now, NWL ICB has said it will return to same-day access hubs again next April with a new model as part of the single offer contract in 2025/26. There has been no concrete indication yet as to what this new model will look like. Local commissioners have only gone as far as to say that different PCNs do not need to adopt the same model.

How it plans to win over GPs is yet to be seen. Sneaking in the same-day access programme as part of the single offer for enhanced services didn’t do the trick this time round. And considering that GPs are not being consulted in the drawing up of new plans, it seems unlikely a cosy agreement is incoming. 

The worry is that more ICB will follow suit. Already, we have seen in Hampshire and the Isle of Wight attempts to triage all patients through NHS 111. With ICBs across the country being told to provide greater access with diminishing real-terms funding, we will likely see more commissioners come up with similar plans. GPs have been warned.