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Buckman...on pay, negotiating and strikes

Dr Buckman answers your questions on the prospects of a pay rise, what it will mean for GPs and his own future if there's another freeze and whether GPs are right to take more in profit from their practices.

Dr Buckman answers your questions on the prospects of a pay rise, what it will mean for GPs and his own future if there's another freeze and whether GPs are right to take more in profit from their practices.

Looking at the questions directly from GPs. Dr Mary Hawking asks about the income figures from the Information Centre. These take into account private income and income paid by Department of Health to clinical leads. Are there any plans to provide income figures derived on income from general practice alone?

It would be nice. Unfortunately the data comes from Inland Revenue, and they don't compile their data that way. Of course, if we could find pure NHS income and nothing else, and there was a way of extracting that from the Inland Revenue resource, of course we'd do that. There isn't a way of doing that.

Is it something you'd like to see from a government perspective?

There is no way of doing it. There is no way of recording those data. When you fill in your tax return there isn't a box marked ‘NHS income'. If there were, well, clearly you'd do that.

What you could do of course is you could get every single accountant to send their accounts in to somewhere, or sample the accounts. You could do that, and AISMA do that, and there are other groups of accountants that produce those data, but what they couldn't do is link that to the Inland Revenue figures. We have this perpetual problem of linking the information to the Inland Revenue figures, and then trying to interpret what that means.

Do you think other income, and Department of Health income for clinical leads, skews the figures?

I shouldn't think Department and clinical lead income skews the figures, but other income skews the figures. Out-of-hours for a start, out-of-hours, superannuation, the fact that we don't pay IT expenditure anymore. Now suddenly we're not investing in our practices? Well hold on, you've just taken a chunk of our investment in capital in IT, because we don't invest in IT anymore. It's that kind of thing.

There isn't a mechanism that we can think of – other than trawling accounts – for doing it, and to gather those data would be an enormous piece of work. The Inland Revenue does it automatically, but it's just all income, and all expenditure, they can't break it down in a way that would be useful.

A couple of questions on the pay rise – Dr Ross Worthington asks, if as has been leaked in the press we have another year of a zero percent pay rise, will the BMA organise some sanctions or will it fold tamely like the last two years?

That's what I meant by perjorative……….. no I won't rise to it.

If there is zero percent pay, which equals a pay cut against inflation, and we've already had two years of pay cuts, the GPC at the time will take a decision on what it feels it can do. Then that will be discussed within the entire BMA because any kind of action that is taken has to be agreed by the BMA Council, and it's not just a GPC matter. Assuming that happens we will then consider how we wish to act.

You don't negotiate while threatening the person you're negotiating with. Some people will say well, the government threatens all the time, and I understand that argument, but we don't do that. That's not because we're gentlemen, it's because I don't think you get much by telling a minister either you give us this or else we'll go and do something.

I just don't think that's a terribly productive or mature way of conducting oneself, and so we don't do that. In the event of a zero again, I imagine the profession will be outraged. I will be. I've had a six percent pay cut like everybody else, and I want that money back if I can get it.

I also had a letter from somebody saying I should demand interest for the previous two years and a pay rise ahead of inflation. Well I don't believe actually that there are many people in the UK who can go to the person they're in contract with and demand an above inflation rise plus interest on the money they lost out on in the past two years. I just think that's unrealistic

But do I think a pay rise is realistic? Yes I do – after two years of cutting, I just don't think it's fair that we have to be the economic regulators for the NHS, and it's terribly tidy to blame us for all the expenses in the NHS, it's all our fault, absolutely, of course it is… Rubbish.

In the Department of Health's evidence, there was the issue of the earning to expenses ratio and the allegation that GPs were taking a larger percentage of profits. Where do you stand on that?

Well let's start off, GP premises costs have changed, IT investment, as I've said to you already, has changed.

There isn't an agreed ratio. Suddenly they've come up with this stuff. Patricia Hewitt said – Patricia Hewitt said quite a few things that don't connect with reality – ministers believed there was going to be a particular earning to expenses ratio. Where does that come from? I was present at every negotiating meeting, through the entire new contract, and before.

Where has this phrase come from? What is a ‘good' earning to expenses ratio? What is ‘good', when you've just taken out one of the biggest areas of expenditure, and made it an expense on the NHS but not on practices any more? Where did that come from? And the change in super-ann that we've all had to pay. So this idea of a particular some being good or bad or indifferent, where did that come from? Who started that?

Do you believe GPs are taking home more money at the end of the day?

Well of course they have. We sent them a ‘Focus on' document telling them to do that, after last year's pay cut. We told them what to do. We said, you better maximise profits because you're not going to get any more pay. Yes, I'm pleased that GPs have listened to our advice. We published it, we expected them to take notice of it - I'm pleased they have.

So no, I'm not surprised they've taken more profit.

Does it make arguing for next year's pay rise harder?

It makes it extremely difficult. But then again, when you're in a situation where there's no pay rise, what are people expected to do? As I've said, act as the economic regulators for the NHS? No, it's our money, and how I spend it is up to me. Nobody else has their pay or expenses scrutinised in such detail, apart from MPs maybe, nobody else.

Last time you had the LMC secretaries meeting, despite the zero percent pay rise it seemed there wasn't an appetite for action among wider GPs…?

There is an appetite among some GPs for quote industrial action unquote. When you ask them, against whom is this industrial action, bearing in mind that you're self-employed, so whom are you attacking, and with what end in view, how are we going to persuade the government to come back to the negotiating table? Why should they? Certainly some in government as I've already said believe we should have a private health service. They're not really interested in whether GPs get upset or not.

And let's say we did, and we did take action. What action? Are we likely to get every GP to do it in a way that actually is going to persuade government to change its mind? There's no point in taking action because we're cross. We have to take action that is going to produce a result. The idea, ‘we'll take action and we'll all feel better', well will we? Yes, we'll feel better but first, will everybody do it? Secondly, if they do it will it have the effect we want, as opposed to the undesired effect which is that the people who don't like us at the moment will dislike us even more? That's not an argument against industrial action, that's purely an observation that you have to have an end in view, which is, we will win.

If your end in view is just to give the enemy a bloody nose, that's not winning. When you've moved into the imagery of war, with winning and losing, that's negotiation over with. Negotiation doesn't do winning and losing – negotiation does trading.

I'm a tradesman, that's what I do. I trade, and I'm a trades unionist and that includes trading the best deal I can for GPs, which may not be the deal they want, OK, because I also want the 6% made up… The suggestion that somehow the BMA is run by ivory tower people - well I'm not bloody ivory tower, OK. I saw 55 people yesterday just like many other GPs did, and I don't need lectures on how I haven't got my feet on the ground. I put my legs in my underpants just the same way they do.

The fact is I also lost six percent and I also want it back, but if I go in there and thump the table… that's this other belief, I used to believe too when I wasn't on the GPC, you thump the table, you go in and they say ‘Gosh are you really that cross I didn't realise, have the money..'

Well no, it doesn't work like that. You've got to persuade somebody who doesn't want to give you money that they should give you money and it's not that easy, and if all you're doing is saying ‘or else we'll…' well, what will you do? ‘I'll go on strike.' Against who? Myself? Who am I going to go on strike against? Who am I going to hurt?

So there are things that GPs can do that will affect government, but what they have to understand is that those things they can do that are likely to affect government and not patients will not necessarily endear them to opinion formers, who they need to get onside, if they are going to get any more money.

As far as next year then, will you feel as though you've failed in some way if you don't get any pay rise at all?

No, no, no, no, no, no, no. My job is to keep trading. I only came with one promise – well actually I came with ten promises in my manifesto, which you've got – but the key one is to get GPs to hold their heads up high. Yes, if I can get GPs to be rich that would be terribly nice. But I'm not going to come in here and promise that they'll get n% where n is whatever figure people agree on because I can't deliver that. It's not in my gift. It's in gift to go and argue for it, and absolutely I will do that, but if I don't get it that's not defeat. Defeat is a much more complicated thing.

And that's not a cop out. I'm only where I am because somebody elected me. If they think I'm crap they'll de-elect me, they can do that. They can have a motion of no confidence in five minutes and get me out. We saw how easy it was to get out the chairman of the BMA if necessary, so I am under no illusion that I can be disposed of. But I'm not going to stand on a chair and promise something I can't. It's not in my gift to guarantee it. But if I don't try hard enough, that is in my gift.

That's something I have to do. I have to try as hard as I possibly can to deliver a reasonable pay rise for GPs, for all GPs, not just for a selected number, and that's got to be something I must try and do, and I have every intention of doing just that.

Looking briefly at the Formula Review Group, and the global sum formula review, when that came out it was billed as a joint GPC-NHS Employers report, and yet it seemed as though once it came out and made those recommendations a lot of GPs were very unhappy with it. Do you stand by the conclusions of the Formula Review Group?

Yes I do. It showed that Carr-Hill didn't have it that wrong, that's the first thing. It also busted a few myths, in ways that I would not have expected. It also – if we put it into practice – would produce a new generation of winners and losers. Would they be fairer? Well you could argue that they'd be fairer but they'd still be winners and losers. Unless you could guarantee a new MPIG to cope with it, you're going to substitute the present flawed arrangement with a wonderfully fair and utterly impossible arrangement. So no MPIG means no do.

The disagreement was, unsurprisingly, between the managers, who thought OK well let's get on with it and change it because it's fairer, and GPs who said hold on, hold on, you're going to produce an awful lot of people here who are going to lose money. And we never said we were going to implement it. All we said was we wanted the truth, we wanted to know… and Carr-Hill didn't have it that wrong. And I think the case we made for moving from Carr-Hill to the new formula would have to be on a rising tide of income that says that nobody loses. Well we're not in that position.

Is that likely to be a development?

This year?

This year.

I doubt it. The government are still busy saying we're all rubbish, so I don't think they're likely to agree to a rising tide that will slowly buy us out of trouble and therefore MPIG will fade and all sorts of other good things will happen. I just don't think the atmosphere's the kind of thing that's going to do that.

In the meantime then, the people who would have gained under the new formula, they just have to sit and wait it out?

They have to sit and wait it out. Because they've got an MPIG, and the people who would lose under the new formula would not have one. What you're going to do is exchange something which is flawed for something that is perfect – and 50% of GPs will be losers. And I can't agree to that. How could I lead the troops into saying ‘well it's much fairer, some people will benefit from it, but an awful lot of people are going to lose money and you don't get an MPIG in the new world'. People would think we'd have gone mad if we did that.

...on threatening industrial action ...on threatening industrial action

You've got to persuade somebody who doesn't want to give you money that they should give you money and if all you're doing is saying I'll go on strike.' Against who? Who am I going to go on strike against? Who am I going to hurt?

...on Alan Johnson's predecessor ...on Alan Johnson's predecessor

Patricia Hewitt said quite a few things that don't connect with reality.


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