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GPs buried under trusts' workload dump

It is time for the BMA to ballot GPs on mass resignation

We must bring back the spirit of 1966, before our workforce collapses under the strain argues Dr Una Coales

In 1966 the BMA was able to obtain undated letters of resignation from all 23,000 GPs, who threatened to go back to private practice. With this powerful negotiating tool, Prime Minister Harold Wilson and the Cabinet conceded to the BMA. The GP Charter was agreed upon, which became the Red Book, the basis of modern general practice.

However with a growing and demanding patient population and GP on calls 24/7, NHS GPs of the 1990s were getting desperate. In 2003 the GPC was mandated to negotiate a new contract. BMA allowed a ballot on the new GMS (nGMS) contract to be open to all GPs. The majority of GMS GPs were against the nGMS contract but were outvoted by GPs who would not be affected. However most did see a rise in income (though not matching PMS) and opted out of OOHs.

Since 2004, the pressure on GPs has increased exponentially. The loss of MPIG and QOF income, GP premise costs hike, reduction of GP partner drawings four years in a row, workload increases, consultation rates as high as 12 per patient per year (up from 3.5 in 2004), a consumer culture, increasingly onerous micromanagement (20 bodies or mechanisms whereby a GP or practice may be assessed, criticised and/or punished), withdrawal of occupational health support for GPs, pressure to deliver 7/7 8-8 extended access and dumping from secondary care, have all led GPs to emigrate, take voluntary early retirement, give up their partnerships, burn out, and suffer mental health crises.

The proportion of NHS funding spent on general practice has fallen to an all-time low. Practices in my area, London, are closing because of financial unviability. Alas, the profession is fragmented into sessionals, PMS and GMS GPs (unlike 1966).

A BMA ballot on mass resignation would be the opening salvo in a war. An overwhelming vote in favour would force the BMA and GPC into action.

Many GPs have begun to question whether the time is right to start charging for appointments. This needn’t bankrupt poor patients. If the NHS became fully privatised, the public may pay 100% without provision of state insurance for the poor and elderly. But many UK GPs have gone to work under the Australian system, which has a social insurance scheme the UK could copy.

Medicare reimburses 85% of the cost of a GP appointment and patients pay just 15% - that’s $36 from Medicare and $13 from the patient for a basic GP consultation. An overwhelming vote in favour of a system this like would convince DH that we have the stomach for a fight – otherwise we give them carte blanche to carry on decimating GP morale and workforce. 

I call upon the spirit of 1966 to return before it is too late. At over a million consultations a day, UK GPs have been flogged as cheap labour.

We are no longer doormats to risk our wellbeing and livelihood for £3/patient consultation, nor must patients suffer. Time to regain our self-respect before the job kills us and demand industrial action for a new contract, a 21st-century contract, one that allows GPs to transition into semiprivate GPs to treat both the poor and the wealthy side by side.

Dr Una Coales ia a GP in south London and BMA Council member

Readers' comments (66)

  • Hear, hear!! You go Una. Completely behind you on this one and much more. It is time that we as a profession put our money where our mouth is. For far too long its been moan, moan, moan, blah, blah, blah....BMA vote, lost resolution, then capitulate. This cycle has to be broken by real action backed by conviction. The survival of the profession demands it. In your article you highlight all the current changes adversely affecting our practice except for the issues of the pension robbery and seniority swindle. I would argue however that the most important reason for emergency action now is legacy. There is a generation of GPs currently in training who are seeing the future and deciding to opt out before they get sucked in; there are medical students in their masses who are discounting the prospect of even working as a GP; and there a teenagers who are beginning to think maybe medicine isn't for them at all. If nothing else we owe it to those potential GPs behind us and the patients they would otherwise be treating to fight our corner strongly before GPs disappear due to lack of fight, belief and fortitude.
    So good luck Una Coales, you having my full backing and support, and I hope that of many other like minded GPs and doctors who have had enough of the political skulduggery that is NHSE, DoH, CQC, NICE and SOS J Hunt.
    See you at the trenches.

    Disillusioned GP (1yr)

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  • Una Coales

    @2:13 good catch. Yes missed out highway pension robbery, seniority swindle and empty legacy. You are right. If we do nothing, we watch government starve out all NHS GP partnerships.

    Frontline troops cannot survive without funding, supplies, rest periods and to demand they fight 8-8, 7/7 against a continual and rising wave tide of consumerism, entitlement, growing population with EU floodgates wide open and global health tourism too...well how can 7,000 and dropping NHS GP partnerships survive coping with millions in WWIII on their own?

    Yes there is no legacy left when all NHS GP partnerships finally close their doors due to forced insolvency. Even now my youngest is resisting general practice despite her school matching her with general practice as a career.

    It means bright medical students who may have wanted to be GPs, are now being swayed against. Without new GPs, there is no future for the profession.

    No recruits and no legacy mean we watch the ashes of general practice disappear into the wind...as for institutions like the BMA and RCGP, membership may be severely affected if GP as a profession becomes extinct? Time to join forces and demand strike action or en masse resignation, nothing more, nothing less to save general practice!

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  • We are fighting for our livlihoods which the government is determined to steal and gift to their private medicine mates.

    Do you wish to be bankrupt despite working like a hamster ?

    They want to steal our families' assets and force us to work for peanuts for the likes of Bupa or Virgin.

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  • No Una,It will be a field day for the 'Likes of the Daily Mail' .we missed a huge opportunity of this nuclear option during the passage of the NHS bill of Lansley. General practice is at the brink of extinction,partly because of the policies of the successive governments and partly because of few of us doing the dirty work of the governments.

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  • Charging patients risks our alienating our patients, withdrawing en masse from the NHS contract leaves the Government with the headache of how to provide medical care.

    The only danger is that Virgin is waiting in the wings to set up in competition, especially with the boundary changes. This would take time for them to do so there
    would be the complete collapse of the hospital system as there would be no one to intercept the outpatient letters, act on them or act as gatekeepers. No Government would survive the chaos. Unfortunately there would be harm to patients.

    There is harm now due to the fall in care that we can give our patients because we are so under resourced that we cannot see our patients in a timely fashion.

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  • I think colleagues need to ask themselves two questions;

    The first is - Do they think primary care is viable?

    If they answer yes the second question is - How far are they willing to go to keep the NHS contract? will they sacrifice the profession, their T&Cs, their health, their family, and work for free to keep that contract?

    Realistically the answer to the first question is No - primary care is no longer financially viable. Even if there was the will to increase funding as the RCGP is suggesting it will only be a short term prop at best. If one accepts that the current model is not viable then there is a moral imperative to look into other options as Dr Coales is suggesting.

    Colleagues who fall back on 'we must think of the patients', 'its not fair on the poor', 'we are a rich nation' are all correct. Nobody wants to lose the NHS founding principles but what do you do when you accept that the current model will fail? - you have to face up to looking at the alternatives regardless of what the media or the public thinks.

    We need that honest debate on the future of primary care that Dr Una Coales has been brave enough to put forward whether you agree with her or not.

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  • I am surprised that how come most of us have not realised that this current model is no longer viable . Friends times have changed and so we wil have to change to. We either have some sort of co payment system or be ready to work for likes of Virgin ( by the way I have worked for them for last 5 years as part time so know very well how they work)
    We should give up this crap of what will happen to our patients . Do our patients really care what will happen to them or us ? Let's face the reality and accept that time has come to leave nhs unless there are some drastic changes which no politician would want for fear of losing votes ( at the end that's all they care for )

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  • Una Coales

    @10:25 if the BMA submitted unsigned resignation letters or OOHs boycott, general practice would come to a stand still for a week at most, before the PM and government caved in and gave us GPs fair pay and fair working conditions. That is why we have a trade union, to ensure doctors are not exploited, overworked, underpaid, robbed of their pension, bankrupted.

    If we do nothing, 99 surgeries will close in East London and the domino effect begins as 100,000 patients look for a GP practice elsewhere. How safe is it when a patient has to wait 2-3 weeks to see a NHS GP? What if the public knew they could pay £70 to see a private GP on the same day or next? What if we could provide a compromise, co payments as in Australia and Ireland?

    Hospital consultants need to be on our side as without GPs, secondary care is next to collapse. However this means they would then just fall back on their private practice. The problem is that not all parts of the UK can afford to provide private care as the population are mostly deprived. They will lose out.

    We must change to survive!

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  • Dr Coales, you say it like it is. I sincerely hope that your voice is heard loud and clear on the BMA Council. Having recently returned from working overseas I have been dismayed at how broken UK general practice is. The current situation is completely unsustainable as is well known by anyone working inside it. If as a society we want a 24/7 all bells and whistles 21st century health service then it needs to be paid for. The alternative is a pared-down NHS providing essential care supplemented by private care. But what you can't have is demand the former and pay for the latter. This debate needs to be blown right open into the public domain but currently there appears no political will for this to happen. If the only thing that prompts such a debate is mass resignation then so be it.

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  • Bob Hodges

    Well said Una

    At the very least this is a debate that need to be had, and had in the public domain.

    Without significant change, General Practice, and with it the NHS, has not a cat in Hell's chance of surviving the next 12 months.

    Of course, that might actually be the plan............

    Read Jonathan Reggler's paper 'The Guernsey Option' which was rejected by the GPC before nGMS. Then wonder why Dr Reggler now lives/works in Canada.

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  • Una Coales

    Thanks Robert and Bob. Sorry that should say undated signed letters of resignation. Yes we are all making a lot of noise and finally debating this. It does need to be taken to the public forum because the public need to know what happened when all NHS GP surgeries fold within a year and privatisation takes over.

    I still plan on queueing for the soapbox in a couple of weeks at the annual LMC conference in York. They'll have to drag me away, kicking and screaming. I get one whole minute to convince the conference that en masse resignation with 3 months notice to abide by NHS Eng rules or OOHs boycott (not in the contract) is needed to grind this machine to a halt and demand a better contract with fair pay and fair working conditions.

    Next is an emergency ARM BMA motion on the day in June in Harrogate. Don't hold your breath. I predict the agenda committee will attempt to block. Don't tell me why as you guys elected me to speak up for you!

    Keep bringing on the ideas. I am just doing what I am told by you. I took a long distance call from Brisbane earlier this week and listened as a former NHS GP regaled working life in Oz, at $200,000 a year and $400 a week rental for a 4 BR house, less tax, co payments and 20-30 minute GP appointments, it is very sweet.

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  • No other system is as cost-effective overall as the NHS. I don`t agree with the introduction of any form of co-payment as this will change the ethos of the NHS. Instead of talking to Australian doctors, you should talk to Australian patients. Primary care does need to attract a greater percentage of the overall funding and there is a huge opportunity for systems` improvement and better integration which can improve cost-effectiveness even more. But under no circumstances should we try to erode the spirit of the NHS which is free at the point of need-this is really special and unique and we should feel very proud about it.

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  • The BMA and GPC remain disciples of the NHS religion and I fear that they see you, Una, as Judas. As you imply they will block you, mock you and probably try to discredit you rather than listen to the membership.

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  • Took Early Retirement

    BMA = Betray My Associates.

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  • Una Coales

    @7:06 I know. However I have a mandate to represent my voters, to have doctors' backs and to make a lot of noise, so that when the last NHS GP partnership closes and the public look around and cannot find a GP surgery to register with and have to travel miles to the closest Virgin APMS, they will know we GPs of 2014 did try to warn the public, we did try to walk out of this doomed NHS GP contract, we did try to get the BMA to ballot its members on en masse resignation or OOHs boycott, we tried EVERYTHING to save both our profession and primary care for our patients.

    And when Virgin and other private providers are then handed permission to charge 100%, the public will clammer come back NHS GPs!!! We are more than happy to pay a £10 copayment to see our family GP or £100 to attend A&E, we can't afford these 100% private fees!

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  • GHOSTS OF GP PAST (found online at the Derby Gripe on-line newsletter circa 2007):

    "Patients will have to pay £16 a month for the right to see a general practitioner under plans being drawn up by the British Medical Association. The proposals amount to a wholesale privatisation of the GP service, with thousands of family doctors potentially leaving the NHS. The BMA's General Practitioners Committee is drawing up the plans as a result of grow ing frustration with intransigence from the Department of Health, which is trying to impose a new contract.

    GPs insist they are having to deal with far too many patients, with the average appointment time now down to seven minutes, and that their pay is too low. Morale among GPs is at rock bottom, with 86% voting to leave the NHS if negotiations over the new contract failed. The proposals, based on the system in Guernsey, are aimed at boosting recruitment, improving pay, increasing the amount of time they have with each patient, cutting paperwork and reducing interference from the Department of Health.

    Under the new system, adults would have to pay £16 a month in insurance to cover visits to a private GP, who would refer the patients to NHS hospitals or consultants if further treatment was needed. Insurance for children would cost £8 a month, and it would be free for those on low incomes. If they wanted, patients could choose 'pay as you go', paying for each appointment to the GP.

    The plans are being developed by a new BMA committee, the Special Advisory Group, which is looking at alternatives to the NHS. A draft report on the plans said, "There is a radical alternative to the UK method of providing general practitioner services which already exists within the British Isles. The Guernsey option would allow the General Practitioner Service to expand once again. The UK would no longer have the unhappiest GPs in Europe."

    Dr Jonathan Reggler, the member of the General Practitioners Committee who originally proposed the Guernsey option, said, "I've received very favourable support from colleagues. The majority of the General Practitioners Committee believes it is viable to run an alternative to the NHS system." The GPC is responsible for negotiating on behalf of GPs with government, and if it formally recommends the Guernsey system, it will be a critical blow to the government.

    It is certain that Alan Milburn, the Health Secretary, who has promised to keep all healthcare free, will refuse to co-operate with the new system, but doctors believe they may be able to force his hand. 'If a sufficient number of GPs in an area resign from the NHS, it will be impossible for health authorities to reallocate all their patients to other doctors. The Government will have to step in,' said Reggler."

    Disillusioned GP Partner (1yr)

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  • Una Coales

    Thank you Bob and @10:40. Wow the Guernsey option! We have been here before! Reggler went to Canada. Young GPs heading for Oz. Got another email today from a part time salaried female GP who is headed for Australia now that her psych consultant husband has secured a job there.

    Only this time, if the BMA do not act and ballot its members for OOHs boycott or mass resignation, then the entire NHS will collapse before everyone's eyes! Nurse shortage in the 1000s, A&E crisis, GP shortage, closures of GP surgeries...no turning back once the domino starts falling with the imminent closure of 99 GP surgery within the next few months.

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  • Una Coales

    Sorry for the typo, that's 99 GP surgeries.

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  • This Contract is not a Contract, as defined with IMPOSED in it. MPIG, Pensions et al tell us that the DOH just reneges on its agreements at will. Furthermore, here is the Minister stating that ' If you GPs do not accept this Contract on offer, I will impose a worse one' and he DID. That is BULLYING and we just lie back and take it. I have been in your shoes in the BMA, Una. It is so hard to get this lot to change their spots. Do you not hear them at the ARMs - 'Our NHS and we will accept anything to keep it '. Even 50% pay cuts, bankruptcies of it members imposed Contracts, bullying etc and not do anything. It is NOT our NHS. We only Contract to it. If the Contract is untenable as it has been for a few years, we have to resign.
    But, alas, we behave like spineless minnows that hide from the light.
    I will be supporting you at the ARM. Perhaps this time is right as practices face bankruptcy. Imagine seeing 40 + patients a day and still going bankrupt !!!! The system is ruptured. A new one is called for.

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  • It is about time GP's took action, I give them my full support!
    I am appalled at the way GP's are being treated, they spend years training to do their best for patients only to have to prove 'by ticking boxes' that is what they do.

    No other profession is hounded in the same way that GP's are, no other professional has to continually prove that can do their job in the way that GP's are, it feels as if there are too many megalomaniacs in power wanting to control every breath we take.
    Leave GP's to what they trained to do, care for the sick!

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