Jaimie Kaffash and Eliza Parr examine what will happen after NHS England imposed a contract on GPs this week
NHS England yesterday (Monday 6 March) informed GPs about the imposed contract. This came after failed talks with the BMA’s GP Committee negotiators. The imposed contract was expected but was no more welcome as a result.
The letter to the profession, signed by Dr Amanda Doyle, NHS England national director for primary care and community services, set out what the changes would be for 2023/24, plus some direction around the 2024 contract, which is set to bring in major reforms to the profession.
But what does the letter mean for practices in the immediate term? And what are the next steps for the BMA and the profession?
Immediate practical considerations for practices
Despite the understandable anger the letter has caused for the profession, it is actually fairly short on detail – most of which will come when the actual contract for 2023/24 is published.
One of the most worrying parts of the contract for GPs was the contractual requirement for patients to be offered an ‘assessment of need’, or signposted to an appropriate service, at first contact with the practice. Practices will therefore ‘no longer be able to request that patients contact the practice at a later time’, said NHS England.
In reality, it is unclear what is meant by this. Some GPs have speculated that it means that every patient will need to be triaged when they contact the practice. Other GP leaders have told Pulse that this might not lead to many changes when implemented, and that policing any requirement will be an impossibility. But we will need to await further detail before finding out what practices need to do, and how punitive the requirements will be.
There are also changes to the investment and impact fund (IIF) for PCNs to focus on access, as well as QOF changes. This will include targets around two-week waiting lists. Again, we await details.
Automatic access to patient records
GP practices will need to be ready to turn on automatic access for patients to their future records through the NHS App by 31 October 2023. This was supposed to have been implemented last year, but concerns raised by GPs, the BMA and the RCGP saw NHS England delay the original deadline of November 2022. This contract gives certainty, but there is no indication that the safety concerns – which revolve around practices having to check sensitive information, especially for vulnerable patients – have been resolved.
It also confirms that NHS England is still looking to allow automatic access for patients to their historic records – which will be another level of workload, with practices having to look through all the information they have previously added to patient records. But there isn’t any indication as to when this will be introduced.
There will be changes to QOF from April. Some of these are pretty clear, and practices will be able to action them soon enough, such as the removal of indicators, including one around rheumatoid arthritis and a change in the requirements for atrial fibrillation.
However, many of the other changes to the QOF require further details. For example, the letter said that income for ‘register indicators’ is to be protected, with funding paid to practices monthly based on their 2022/23 performance. This will ‘release £97m’, said NHS England. These register indicators are those where practices get QOF points for maintaining a register, which involves minimal workload. So, in that case, it is concerning what NHS England means when it says £97m is being ‘released’.
There are new indicators around cholesterol and mental health, but details are needed on these. And the QI modules next year will focus on workforce and wellbeing, and optimisation of demand and capacity management in general practice, but again practices won’t be able to plan without seeing the actual contract.
The suggestion that QOF is to be ‘streamlined’ in the major 2024 contract also gives little clue as to what will happen – understandably, perhaps, considering it will be subject to consultation.
PCNs will be able to employ advanced nurse practitioners through the additional roles reimbursement scheme from April, and will be able to employ more mental health workers. Of course, the issue will still remain as to where to find them.
NHS England have mandated the use of ‘cloud-based telephony’, which will be provided though their own framework. However, this won’t need to be introduced until 2025.
BMA’s next move
The truth is, the requirements in the contract are likely to be frustrating rather than onerous – but this will of course depend on the details.
However, the BMA’s main issue with the contract offer they rejected was the lack of further funding beyond that agreed in 2019 as part of the five-year deal. But with inflation currently sky high, practices need more than the circa 2%-3% uplift they will receive.
More coverage of the GP contract imposition
Regardless, it is the lack of funding that will drive the BMA on to take further action. The first thing they need is to get agreement on the next course of action from the GP Committee as a whole. Pulse understands that the wider GPC only found out about the imposition through Pulse’s reporting yesterday. As Dr Michelle Drage, chief executive of Londonwide LMCs and a member of the GPC, said on her blog: ‘To me, the way in which the outcome of the unsuccessful contract negotiations has been made public feels unprofessional, and an example of bad faith.’
Now, there are talks with the wider BMA about funding an emergency GPC meeting to discuss the next move. If and when the GPC does convene an emergency meeting, it is almost certain they will conduct a consultative ballot with GPs to gauge the mood of grassroots GPs. The BMA has just announced the results of a consultative ballot with consultants, which found an appetite for strike action. The likely consultative ballot with GPs won’t actually give a mandate for industrial action, but it will inform a future ballot.
It is pure speculation for now, but there might be other suggestions on such a ballot – something closer to ‘work to rule’, with practices refusing any non-contractual work
The BMA ran an indicative ballot in November 2021 on what action GPs would be willing to take against NHS England and the Government’s access plan, and results showed that over a half of GP practices would support withdrawal from the PCN DES. This might well be on an indicative ballot again.
Potential industrial action
Following NHS England’s announcement of a new contract for 2023/24, the BMA GPC said it will now ‘enter serious discussions with our membership and the wider profession on what action we take next’.
The BMA had previously set up a working group preparing for GP industrial action, which was understood to be floating options going further than before.
It is not as simple as GPs ‘striking’, however. GP partners are not employed, and their contract to supply services is a commercial one rather than an employment contract.
This means they cannot ‘strike’ in the same way as junior doctors, for example, and any action along the lines of a strike would be considered a breach of a commercial contract.
However, last month legal experts told Pulse that withdrawing services for a day is an option on the table for GPs if they wanted to take collective action.
Professor Gregor Gall, an industrial relations professor at the University of Glasgow, said GPs could theoretically decide to shut for the day and therefore breach their contract.
He said: ‘Depending upon the content of those contracts, there could be financial (likes fines) and other consequences for doing so (like termination).’
But he said that given existing demand pressures upon GPs and the lack of a new supply, any health authority is not likely to do much that would jeopardise the continuation of those contracts, for fear of creating even more disruption and eliciting a huge public backlash.
Daniel Wilde, a partner specialising in employment law at Harding Evans solicitors, explained that GPs cannot be in an industrial dispute with their employers, since they are not employees, but they can be in a dispute with their commissioners.
He added: ‘As long as the BMA’s ballot is lawful, there is no reason GPs cannot close for the day as a form of industrial action (or only offer urgent care).’
Appetite from GPs on how far they will go
Despite moves from the BMA towards industrial action, there appears to be mixed support for it among grassroots GPs.
Retired GP and chair GP Survival Dr John Hughes said there has ‘certainly been a strengthening in the thoughts about taking industrial action’.
He puts this down to the way GPs were treated in the pandemic, the media’s portrayal of GPs, and most recently the new contract announcement, which is ‘another nail in the coffin’.
Instead of a walkout, Dr Hughes said ‘undated resignations’ would be a more viable option, which is the process whereby GPs resign en masse from the contract and set up independently.
He describes this as the ‘nuclear option’ and the one with ‘the greatest leverage’, but that another consultative ballot probably needs to run before action like this to gauge the views of most GPs.
In response to the contract imposition, the Doctors’ Association UK (DAUK) said it will be watching the BMA’s next steps closely and believes industrial action is the only option.
Dr Lizzie Toberty, DAUK GP lead, said: ‘This contract imposition seems to imply NHSE does not view GPs as equal partners in providing high quality patient care, but as a profession who need to be beaten into submission.
‘If we as a profession do not collectively act to resist these changes, I fear we will see an acceleration of two-tier medical care, similar to that of dentistry.’
But there are concerns from some GPs about the potential public opinion on strike action, and also its effectiveness as a tool to improve the general practice landscape.
Dr John Ashcroft, a GP in Derbyshire, said that while the current Government approach to general practice is ‘fundamentally wrong’, industrial action does not seem the best option as ‘there is a risk it will turn people against us’.
He said that not striking and lobbying for a better contract may be more effective: ‘Perhaps we have to take the higher moral level and say “we’re not going to go on strike for this, it’s not going to help patients, but you as Government have failed to invest in general practice.”’
It may need a stronger consensus for GPs to take any kind of ‘nuclear option’, in that case.