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Are you prepared to take the nuclear option?

resign button background 3x2

resign button background 3×2

Ministers have been given an ultimatum – come up with a better remedy for the general practice crisis within three months or face a ‘trade dispute’ with GPs. GP leaders have given their verdict on NHS England’s rescue package – the General Practice Forward View – and it is a resounding thumbs-down.

Chaand Nagpaul - LMCs 2016

Chaand Nagpaul – LMCs 2016

LMC leaders queued up to decry its promise of ‘jam tomorrow’ in the form of £2.4bn extra funding a year by 2020. They voted overwhelmingly that it is not an adequate response, and there are grounds for industrial action.

Instead, the GPC is insisting its own manifesto – the Urgent prescription for general practice – is adopted wholesale, including workload limits, an end to CQC inspections and reduced responsibility for home visits. 

The motion passed at the LMCs Conference last month calls for a ballot on the willingness of the profession to submit undated resignations and/or other forms of industrial action if nothing changes by August. It was approved by BMA lawyers beforehand – allaying any fears over the legality of such a move.

Palpable anger

Dr Jackie Applebee, chair of Tower Hamlets LMC in east London, put forward the incendiary motion saying that GPs need to ‘put down a marker’ to the Government by letting it know that they ‘are willing to consider industrial action to preserve general practice’.

LMC leaders lined up to argue that mass resignation was unavoidable. Dr Tim Parker, a GP in Shropshire, even had a letter prepared, which he handed to GPC chair Dr Chaand Nagpaul, saying: ‘The GPC needs ammunition. I am prepared to give the negotiators my letter of resignation now.’

The motion follows the Special LMC Conference in January, which gave the Government six months to come up with a credible rescue deal.

But the publication of the GP Forward View means this vote could be more significant, as it allows LMCs leaders to detail precisely what they want to happen. GPs’ anger is palpable, and the concessions won after the junior doctors’ strike action this year could offer the encouragement they need to take action.

A Pulse survey carried out immediately after the publication of the GP Forward View reveals some support for action, with 45% of 524 GPs in England supporting mass resignation from the NHS due to the current state of general practice, with a further 25% undecided.

Yet there is little sign of the Government or NHS England taking the threat seriously. An NHS England spokesperson told Pulse: ‘The widely supported new General Practice Forward View, backed by a groundbreaking £2.4bn action plan, will help tackle longstanding pressures in primary care, but of course we know this a step on the journey, not the final destination.’ 

LMCs Conference 2016

LMCs Conference 2016

The Department of Health declined to comment on the vote, saying it was up to NHS England to respond.

But some GP leaders argue that even the modest level of support suggested by the Pulse survey will be hard to achieve.

They raise the spectre of the pensions ‘day of action’ in 2013, which initially enjoyed plenty of backing. This support failed to materialise on the day itself, when only one in four practices closed, providing urgent care only. This left BMA powerless to prevent the unpopular 2015 pension reforms – increasing contributions and raising the retirement age – going through with no changes.

GPC prescribing subcommittee chair Dr Andrew Green says: ‘GP principals in my area will not sign undated resignations. The implications of being left with redundancy payments, long leases or large capital accounts are simply too great.

‘I love general practice, I have given my professional life to it, but I will not risk personal bankruptcy for it and we shouldn’t ask others to do so either.’

Dr Green adds: ‘For any industrial action to be successful three things are needed: unity, a well-defined and achievable aim, and public support.’

He says the junior doctors were ‘incredibly impressive’ in winning agreement from the Government, but adds that ‘even then the success of their campaign is uncertain’.

‘Due to our diverse profession we will be highly unlikely to get that level of unity, certainly not for undated resignations. To display that in the very public way in a ballot may harm rather than help our negotiating position,’ he says. The RCGP says the vote shows the ‘strength of feeling’ in the profession, but has refused to comment further (possibly because it has wholeheartedly welcomed the GP Forward View).

We need to choose one or two things that don’t harm patient care

Dr Jackie Applebee 

The GPC Executive’s response to the vote has been studied. Deputy chair Dr Richard Vautrey says the ballot will go ahead in three months if there are no ‘tangible reductions in workload’.

He tells Pulse: ‘We will be pushing NHS England to agree to accept our Urgent prescription as demanded by the conference but we need to do more than that. Fundamentally that means addressing the funding gap in general practice – which is as serious, if not more so, than the 2015/16 £2.45bn shortfall in secondary care – together with making some really tangible reductions in the workload pressures that are currently leading to increasing numbers of GPs becoming ill themselves.’

But the GPC is reluctant to push mass resignation as an option, and is actively looking at alternatives.

Even Dr Applebee says mass resignation is ‘merely a marker’ rather than a serious threat. She says the GPC is already looking into what other action it could take, adding ‘it will be along the lines of working to contract and not doing anything over and above’.

She tells Pulse: ‘In my view we have to pick one or two things that we ask all GPs across the country not to do. Our contract is very complex [and] if we are not organised about this and just ask people in a vague way to work to contract it won’t work. We need to choose one or two things that don’t harm patient care.’

She says she would like to see action to address onerous regulation but fears this would be difficult: ‘I would like to see GPs doing something around CQC; the cost is exorbitant and it takes us away from patient-facing activity. If we could redeploy the money and time spent on CQC into patient care this could only be a good thing, but I believe that this is not legal, so it’s not on the cards.’

How will GPs outside England be affected?

The GP Forward View only applies to England and as such the vote at the LMCs Conference does not apply to GPs in the devolved nations. Indeed, it reflects the more positive relationships between the profession and the governments in the rest of the UK.

LMCs in Scotland and Wales voted against submitting undated resignations at their national conferences. Negotiations are ongoing in Scotland to develop a whole new contract for next year.

Dr David Bailey, deputy chair for GPC Wales, says: ‘The vote was in relation to the GP Forward View so is by definition English although we would fully support whatever our colleagues in England decide.’

GPC deputy chair Dr Richard Vautrey says: ‘We will be looking at the implementation of all the other elements of the motion too and will keep you informed about that, but it is likely to have an England-only focus as the Scottish and Welsh LMCs conferences did not support this.’

Doncaster LMC medical secretary and GPC member Dr Dean Eggitt predicts the whole process will be stymied unless the GPC shows more imagination.

He says: ‘What I think will happen is that GPC will go away, look at the motion, procrastinate on the words of the motion and ballot the profession on their willingness to do industrial action, and that will sit in the closet as a threat but will not result in formal action.’

Instead, he says, the GPC should be focused on getting out a more urgent message, aimed directly at the public, about the pressures GPs are under and the dangers to patient safety.

He says: ‘Our colleagues are dying by suicide. Our colleagues who are depressed and cannot cope on a day-to-day basis don’t want to see threats, they want to see action. We have to do something now. We cannot wait another six months, another year.’

But Dr Samir Dawlatly, a member of Birmingham LMC and a GP in the city, has a simpler solution, first suggested by Pulse editor Nigel Praities earlier this year: ‘We like our patients, we care for our patients. We don’t want to make life hard for them. So there are all these hurdles that a lot of people recognise in terms of exploring other options.

‘I think the simplest one would be to say it’s not safe to carry on as we are, we are all going to close our lists. I think that would be least disadvantageous to our current patients. You’ve got NHS area teams who are making it very difficult to close lists but I think closing lists is probably the minimum that we could do.’

This debate will continue within the profession throughout the next few months, and it one that could have a powerful influence on its future.

What the GPC will be demanding…

  • An end to annual contract negotiations
  • A maximum number of patients that GPs can deal with in a day
  • Fifteen-minute consultations where necessary
  • Reduction in home visits
  • A price list for services that are not under GMS
  • Separate contractual arrangements for nursing and residential homes
  • Removal of GPs’ role in assessing eligibility for things like bus passes, parking badges, housing, gym memberships and other ‘non-NHS’ work
  • Ending of the duplication of the current CQC registration process and replacing ‘inspections with targeted assessments’

Source: GPC’s Urgent prescription for general practice, April 2016


… and options for industrial action if they don’t get it

  • Submitting undated resignations
  • Refusing to pay CQC fees
  • A co-ordinated drive to informally close practice lists to new patients
  • Refusal to co-operate with appraisal and/or revalidation
  • Working to rule by stopping all non-contractual work
  • Setting a limit on the number of consultations in a day, and referring all urgent work elsewhere if it is breached
  • Safety-first policy – lowering the threshold for all investigations and referrals
  • Co-ordinated stoppage of all out-of-hours work

Source: Back-of-the-fag-packet list from Pulse, June 2016