As Dr Farah Jameel takes the helm at the BMA GP Committee, Rachel Carter looks at the key priorities for the first-ever female GPC England chair
It’s the end of a difficult year for primary care, and GPs aren’t feeling very festive. They have repeatedly found themselves at the centre of media criticism – and on the receiving end of abuse from patients – all while continuing to work under immense pressure with crippling workloads.
So what a time for incoming BMA GP Committee England chair Dr Farah Jameel to start. She is picking up the baton at a time when the profession’s relations with NHS England and the Government are at an all-time low.
In her first message to the profession, Dr Jameel said she wanted to ‘reset the relationship’ with the Government, and – aptly for the time of year – adding: ‘I promise to bring hope back into the profession.’
This is quite the challenge. Her election follows the surprise resignation of Dr Richard Vautrey after four years at the helm. He said it was the ‘right time for a new chair to take on this role’, but there had been some discontent among GPC members and the profession about the BMA’s struggle to counter the negative media.
This reached a head in October when the Government and NHSE’s plan to improve GP access – dressed up as a ‘support’ package for GPs – was announced. Among the worst of the measures it included were plans to penalise practices deemed to be in the bottom 20% on access, including provision of face-to-face appointments – which the BMA’s own analysis described as ‘just another stick to keep beating practices with’.
The direction Dr Jameel takes will have huge implications for GPs in England. Here, we review the biggest tasks in her in-tray over the festive period and beyond.
Response to the NHS England plan
At the very top of Dr Jameel’s in-tray is the BMA’s response to NHS England’s access plan, and whether that would involve industrial action.
The BMA advised GPs ‘not to engage’ with the plan when it was released. After an emergency meeting, it announced plans to poll the profession on what the response should be – including potential industrial action.
However, it soon emerged that national media headlines around ‘strike action’ were overblown. First, the poll was advisory, partly due to trade union law, which mandates a set amount of time between a decision to ballot on industrial action and the ballot itself.
Second, the poll contained no option for full withdrawal of labour. Instead, five options were given. Two involved ‘industrial action’, as they constituted a breach of the core contract: refusal to comply with the requirement for GPs to declare annual earnings over £150,000 and with the requirement to provide Covid exemption certificates.
There was an option to participate in a ‘co-ordinated and continuous change’ to GP appointment books, to affect the quality of data NHS England is looking to collect. Two other options involved non-engagement with the PCN DES (see next box). None of these three amounts to industrial action.
The release of this poll seemed to produce an immediate success for the BMA. The union said on 18 November – the same day as Dr Jameel’s election – that it had been told the health secretary was delaying the requirement for GPs to declare earnings.
The survey closed on 14 November, and the BMA had originally said the results would be shared with members on 18/19 November. However, earlier that week, the BMA began to row back on that, telling Pulse it had no ‘immediate plans’ to make the result public as ‘there is no need to do so’. It was the top item at Dr Jameel’s first GPC meeting as chair. But it soon emerged the results might not be made public.
Dr Jameel wrote in her first bulletin to members: ‘Following a thorough and engaging debate amongst committee members, we are now analysing the results in detail before deciding on the next steps, which we will communicate to all members in due course.’
What action will follow remains to be seen. One of the reasons for the BMA’s change of heart might be that the threat of ‘industrial action’ doesn’t carry much weight. The apparent delay to declaration of income leaves refusal to participate with Covid exemption forms as the only ‘industrial action’ remaining. As Gateshead and South Tyneside LMC chair Dr Paul Evans says: ‘Realistically, declining to issue Covid vaccination exemption certificates will impact a very small number of people and the impact on NHS England will be zero.’
But action around the Network DES is still on the table – and that would have a huge impact on NHS England…
The future of PCNs
While industrial action was the headline measure in the BMA poll, the options around the PCN DES are arguably more important. Dr Jameel may find this the hardest issue on which to find a consensus in the profession.
PCNs were introduced through the Network DES in England in 2019, bringing together practices in groupings of 30,000-50,000 patients to deliver more services within primary care. PCN membership is voluntary but more primary care funding is set to be funnelled through networks in coming years, and it is NHS England’s flagship policy.
A boycott would have a major effect on NHS England. PCNs are central to plans to reshape the NHS next year through the new NHS bill. NHS England rightly or not sees them as the most effective way of tackling long-term conditions at a population level. And much of the ‘support’ package was predicated on practices working within these groups, with some funding being funnelled through the ‘impact and investment fund’, which is only available to PCNs.
It seems the GPC and other GP leaders are targeting PCNs as a result, hitting NHS England where it hurts. There have been a number of developments on this front.
In October, the GPC passed a motion calling on practices to submit undated resignations from the PCN DES. These would be held by LMCs and only be issued on collection of submissions from ‘a critical mass of more than 50% of eligible practices’.
The motion also called on practices to pause all ‘additional roles reimbursement scheme’ recruitment – the central pillar of the whole PCN policy, which allows networks to hire non-GP staff – and to disengage from the demands of the PCN DES. However, although there were reports of some PCNs submitting resignations to their LMCs, in effect nothing will happen until the BMA releases the results of the November poll.
The poll gave two options relating to networks: ‘participating in a coordinated and continuous withdrawal from the PCN DES at the next opt-out period’; and ‘disengaging, continuously, from the PCN DES before the next opt-out period’. These would not breach the core contract, but would see a cut in practices’ income, accompanying guidance explained.
Dr Paul Evans says local GPs recognised withdrawal from the PCN DES was ‘the only useful leverage that practices had left’.
‘A straw poll of practices showed overall there was support for this,’ he says. ‘Maybe reluctant support because by and large people want to make the PCNs into which they have invested time work, but recognition that we had nothing else left against a Government that seems hell bent on destroying general practice.’
He adds ‘the majority’ of practices locally said they would submit undated resignations from the DES in the opt-out period next spring.
But Lancashire GP Dr Russell Thorpe says he would be ‘surprised’ if any practices in his PCN voted to leave the DES.
‘I think the various practices in our area seem comfortable with the idea of the PCN. The ability to employ the additional roles staff has definitely benefited some practices… and obviously there is an income stream from working with the PCN as well.’
The LMCs conference later this month sees motions warning the PCN DES was a ‘Trojan horse’ that threatened the independent contractor model, and saying the GPC should negotiate that PCN funding be moved into the core contract, (see next box).
Dr Zishan Syed, a GPC member in Kent, says: ‘The profession is becoming sharply divided. It’s not even divided over the contract, it’s divided over a DES, which is a very bizarre situation for the profession.’
Much of what happens with these actions will feed into negotiations for a new GMS contract, to be brought in from April 2022. Last year saw few changes, partly due to the effects of the pandemic, and partly because a five-year contract had been introduced in 2019, with funding guaranteed and the expectation that there would be minimal change throughout the contract’s term.
But this might not be the case this year. Since last year, there has been a new health secretary, a new NHS England chief executive, a new GPC chair and a lot of murky water under the bridge – including a suspension of talks between the GPC and NHS England earlier in the year.
And there seems to be a change of attitude within the GPC. At its October meeting, committee members instructed the GPC executive in a motion to negotiate a new contract to replace the current one, which they said was ‘underfunded and unsafe’.
With such a mandate behind her, Dr Jameel may find herself in more wide-ranging negotiations than last year. And there are some obvious discussion points on the table.
NHS England and the Government have made no secret of their push for GPs to conduct a greater proportion of appointments face to face. In the winter access ‘support’ package, NHS England issued veiled threats around practices that weren’t offering enough, including potential breach of contract notices.
But in order to issue such a notice, NHS England must prove that a practice’s level of face-to-face appointments amounts to a failure to meet the ‘reasonable needs’ of patients.
NHS England’s new chief executive Amanda Pritchard has said there will be no concrete targets for the proportion of appointments that should be face to face, but it seems likely NHSE will try to include clauses in the contract explicitly stating that patients should receive an in-person appointment if they request one – something Dr Jameel and her team will no doubt wish to counter.
There is a push from NHS England for more funding to be funnelled via PCNs but also a pushback against such action from grassroots GPs.
In the agenda for the England LMCs Conference on 25 November, LMCs have called on the GPC to withdraw support for the model and refuse to negotiate any new work or funding for PCNs, or an extension to the PCN contract beyond its 2023 end date. Instead, they said, the GPC should negotiate that PCN funding be moved into the core contract.
If passed it will give a strong brief to Dr Jameel to resist any attempts to direct core contract funds via the DES.
Declaration of earnings
The contractual requirement for GPs to publicly declare annual earnings of £150,000 or more has long been a source of contention for GPs.
It formed part of the industrial action advisory ballot, and the BMA had said it would provide legal support to any GPs who decided to breach this clause.
GPs initially had a deadline of 12 November to declare earnings. Sajid Javid’s decision to postpone the implementation is welcome, although its complete removal from the contract will surely be up for discussion.
The access plan introduced new measures to tackle secondary care workload dumping. It said providers must ‘assess and address certain processes that generate avoidable administrative burdens for GPs’ and should be ‘held to account’ over unnecessary workload dumping.
‘Removing the need to send email attachments or paper letters requiring manual processing’ later this year will also improve transfer of information between secondary care and GPs, NHS England said.
This area will no doubt be a key focus for Dr Jameel, who has made GP workload a priority. Her work on dumping has included efforts to stop trusts discharging patients who miss their first appointment and promoting consultant-to-consultant referrals.
The BMA succeeded in getting measures to reduce workload dump into the 2017/19 NHS standard contract, including encouraging referral between consultants. But implementation has been patchy, as Dr Jameel has often stressed. Her own workload is set to increase and GPs will hope she rises to the challenge.
Outgoing BMA GP Committee chair: what Dr Richard Vautrey achieved
Leeds GP Dr Vautrey was elected GPC chair in 2017, having been part of the GPC negotiating and executive team since 2004. At his election, he commented there was ‘much to do to deal with the workload pressures, resolve the workforce crisis and improve the morale of GPs’ but he believed ‘a brighter future’ was possible.
One of Dr Vautrey’s notable achievements was to negotiate away from a yearly contract for GPs and instead secure a multiyear deal – which also included a £2.8bn funding boost.
He also ended the burden of indemnity for GPs – they have not had to pay fees to medical defence organisations for NHS work since 2019.
The BMA also credits Dr Vautrey with turning around the decline in GP pay, improving care for patients with long-term conditions, and increased funding to help young GP partners.
Finally, he has led the profession through the pandemic, including the major shift to remote working and delivery of the vaccination programme.