BMA GP Committee England chair Dr Katie Bramall-Stainer tells Anna Colivicchi about contract negotiation ‘red lines’ and whether GPs will be called upon to take industrial action.
GP contract negotiations
Q: What is on your mind at the moment during negotiations for the next GP contract?
A: We’re in a really precarious place in general practice. You wonder if the Department of Health and Social Care and NHS England intended to go this far, in terms of pushing contractors and squeezing income at practice level.
Traditionally, when you’re a partner, your accountant comes in September, and they talk to you about where your finances are and how it’s looking for the rest of the financial year. I can’t help but wonder that we have seen the message land across the majority of our six and a half thousand practices across England that their finances have just tumbled through the floor.
That’s then being compounded with the 6% pay rise, which was never a 6% pay rise – it was a 6% uplift to that portion of the global sum that covers other staff expenses. It turns out that the means behind that calculation are really out of date and they’re based on the evidence of only about 60 to 70 practices back in 2016, so that needs sorting out. Actually the whole episode has been a very helpful learning opportunity, but it raises more questions than answers.
You could argue: well, it’s great. That £253m is there. But what I see is a huge amount of complication on the back of it. What has been offered has escalated expectation and has been very damaging in terms of relationships between not just salary GPs and their employing GPs, but also practice nurses or the practice staff, until the loser at the end of the day is the patient. Because when the services of your local surgery are squeezed so much, the quality of the care that’s going to be provided is going to deteriorate.
[NHS England and the Government] have hit their targets, they’ve hit their 50 million additional appointments, they’ve hit their 24,000 additional roles. But we are no further ahead in terms of number of GPs.
Q: What are your ‘non-negotiables’ in the contract negotiations? What have you been asking to avoid industrial action from GPs?
A: I’ve played it really straightforward. There’s a lot of reset expectations going on and we’ve been very open about the fact that this stepping stone year must be about GPs feeling safe, their contracts feeling sustainable, and giving hope to the profession, because I think actually there are a lot of GPs out there who are choosing not to undertake substantive NHS posts, because it’s felt to be simply too toxic.
I was lucky enough to meet Victoria Atkins in her first week [as health secretary], and I said, ‘Wow, you’ve got a section of the NHS that hasn’t yet taken any collective action, which faces unlimited liability’, and her jaw dropped. She’s a criminal barrister, she understands what the consequences of that are.
We cannot practise in the 21st century under a Partnership Act of 1890 that is not just Victorian in its outlook, it’s Victorian in its character, and it is terribly unrealistic to expect future partners who have grown up amongst a society with much greater expectations around regulation and administration to go: ‘Yeah, no problem, unlimited liability, sure’.
You can argue that there’s been a generational shift and nobody wants to be a partner anymore. That is not what I see. Actually, the things that are really valued in general practice are the professional autonomy, the fact that rather than having to follow that set, NHS England-branded algorithm of treatment, you are allowed to think outside the box and take responsibility for being a genuine independent advocate for your patient, rather than a banal standardisation of services that everyone must conform to at a trust. That is the the special magic of British general practice.
It may well be that the independent contractor model will need to evolve, but for any evolution needs to feel safe, it needs to be carefully thought through, it needs to be evidence-based, and it needs to be over a significant period of time that is longer than a one political party electoral cycle.
In terms of what we’ve asked for, we’ve asked for flexibility. We appreciate and acknowledge that NHS England and the Department of Health are not prepared to discuss anything other than their single narrative around the pursuit of the goal of integrated neighbourhood teams. And there is no other show in town. So let’s talk about what we can suggest, which will make a huge difference for contractors and the profession on the ground but which might not really make much difference to the Treasury, to that fixed financial envelope, to the Department of Health and to NHS England.
[General practice] has seen productivity rise between 4-10%, depending upon your metrics, and has brought zero deficit. We can’t go into deficit because otherwise we’re bankrupt and we can’t hold the contract. So where’s the reward for good behaviour?
If you want financial productivity, organisational efficiency, agility, responsiveness, ingenuity, you have to rely on the on the partnership model of general practice. And yet, what we’re seeing is this intransigence, and this insistence on looking at other ways of delivery. It feels like at every front at every level, there’s this blind insistence on choosing not to invest in general practice.
Q: Will GPs be added to the ARRS? Is it something you are asking in the negotiations?
A: Absolutely, that is a red line for us. At the moment, there is no means to allow GPs in subsidised roles such as the additional roles reimbursement scheme. To me, that would be an obvious solution because if what the Department of Health and NHS England suggest is that the financial envelope is incredibly tight and the country is in a dreadful parlous financial state of debt that no money is available, surely then we need high-trust, low bureaucracy, flexible, creative solutions.
The challenge that is given back [from the Government and NHSE] is: how does that prove additionality? The comeback to that is that GPs aren’t additional. Then let’s describe a number of GP roles which will absolutely be additional and which would bring [NHSE] what they want from a neighbourhood integrated team angle and what we would need, for the work that we’re already doing in practices, but that actually falls outside the contract.
It could be a focus on child health and safeguarding, because of course, we’re not going to not do safeguarding, even though it’s not in our contract. Or you could have a named GP at a neighbourhood level, which will complement the named GP at a practice level and a named GP at a system level. Or you could have additional-roles GPs that lead frailty provision across a community. You could also have additional GPs in the enhanced access setting that could then provide greater resilience for those appointments, allowing substantive GPs to continue long-term condition management.
Personally, I’d rather these roles were funded through GMS. I think it is a sad day that the GPC has to argue for GPs in additional roles, and I think that shows you what we’ve had to inherit, but we are where we are and we have to try and make the best with what we have. An improvement on the status quo is all I’m interested in, it has to be a demonstrable improvement for practices.
Q: Do you think continuity of care is to be included in the contract and how can it be measured?
A: I don’t think we’re in that space. Before you can even get there, you’ve got to rebuild general practice. Before you can start to contractualise continuity of care as an outcome, you’ve got to have the workforce there to do it. And at the moment, everything is predicated on access. Let’s put access to one side, because at the moment, the patient outcomes and the evidence is in support of continuity of care, it is not in support of access or multiple episodes of care that are fragmented.
I want to see continuity measures embedded, because I believe that will bring the greatest value for money to the Treasury, the greatest evidence base for improved patient outcomes for our population, and the greatest joy brought back to the amazing job that is being a GP, if it’s allowed to thrive.
The employment crisis
Q: Do you think that from a recruitment crisis, we’re going into an employment crisis because of what you’ve just described?
A: I think we’re in it. In a very quick timeframe, we went from a narrative and discussions about the paucity of GPs, the attrition of GPs per head of population, the loss of around 2,000, full time equivalent GPs, to suddenly here we are in January 2024. And we allegedly have thousands of GPs who have recently CCTed and completed their training who are unemployed. You would always see a slight bulge in those GPs that have completed their training in the August to January window, but we are going to lose those GPs from the profession that we’ve trained, because practice can’t afford to employ them.
We’ve seen the messages play out across Med Twitter, across GP social media, around the well-founded concerns of younger colleagues being frozen out of practice employed roles and locum roles. It’s a very difficult narrative for the public to understand, let alone for members of our own branch of practice to appreciate the reasons for, and even other branches of practice look in absolute bewilderment and puzzlement as to why we’re in this situation.
Q: What about industrial action? Are you going to ballot GPs regardless of the outcome of the negotiations?
A: We’ve heard it said before that chairs of GPC have labelled conference nothing but a pantomime, nothing but a distraction. As a former chair of the UK conference, for me conferences are sacrosanct, the voice of LMCs is paramount – you ignore conference at your peril, you ignore grassroots GPs and what they’re saying at your peril. And the policy that came out of England conference on 24 November, was that any new contract offer would need to be put to a referendum of the profession. And I truly believe in conference policy and listening to it and acting on it. So therefore, I shall be putting this year’s contract offer – whatever it ends up looking like – in a referendum to the profession.
We meet on 1 February and I anticipate that a referendum will be put in process to the profession from the next week after that. What happens on the back of it, that’s not for me to determine. We’ll have to see what the profession says, but depending upon what the profession responds to us, it may then lead us to consider an indicative ballot later in the spring.
If NHS England and the Department of Health feel they must impose a contract that we don’t agree with from April, and if an indicative ballot suggests that this is felt strongly enough by the profession, then I think we would have to move to a formal ballot after April. I could see that playing out into the summer. And I could then see us looking at putting in place a menu of collective action that might be cumulative, sequenced or complemented with longer-term action in the background. I can see that collective action playing out into the autumn, and even into winter. And of course, we know what’s happening in autumn and winter: a general election.
So if we are forced down this road, we will make access and protection of your local GP, in your family surgery, the doorstep conversation during the election campaign – which it needs to be, and it’s time we spelled it out to the public and called out what is happening to us as a profession.
It’s sad that the one part of the NHS that has not taken action, that has increased productivity, that has contributed 0% to a deficit, is being forced into this position. I think it will be a catastrophic failure on the part of colleagues in NHS England and the Department of Health, that they have not gone to the Treasury to seek resource to match the offers they have made to other branches of practice.
The future of PCNs
Q: Do you think PCNs will be scrapped?
A: PCNs are the only show in town as far as the Department of Health and NHS England are concerned. Working at scale appears to be the only show in town as far as many other parties’ aspirations are concerned. But I think it’s a fluid conversation. And it is beholden on us at GPC, on LMCs across the country, on practices across the nation, that we make the case for the strength of the local surgery.
I was always against the PCN DES, but I voted for it because every single member of GPC England voted for the PCN DES apart from one member, who chose to abstain. And it was because we were told ‘if you don’t go for this, [the funding] will go to community trusts’ and ‘if you don’t go for this, you won’t have Crown-backed indemnity’. This is not what the executive team believed, it’s what they were told by their then NHS England colleagues.
We have to remember at the time that there were GPs being prevented from practising because they were facing such staggering sums of indemnity costs. And we can now look back with the benefit of hindsight that actually some medical indemnity providers were facing financial pressures of their own, where this actually was going to be a compulsion upon Treasury to find a solution. We can see that actually community trusts are in no shape to take on the services that are required of the PCN. So on on the basis of those examples, I believe GPC England was fed a lie.
But that was then and this is now, and we have to look forward, we have to be realistic. We have to be responsible about where we are, and recognise that this is not just people’s careers, not just their livelihoods, it’s their businesses that they also owe to their members of staff and their patients that they have known for decades.