This could be the first time a Welsh GP contract is imposed

Eliza Parr speaks to BMA Wales’ GP Committee chair Dr Gareth Oelmann a few weeks after he walked away from contract negotiations. He says the Government failed to make a ‘credible’ financial offer, but what happens next?

Q: What’s happened with GP contract negotiations in Wales so far?

A: We’ve been unable to agree with the Welsh Government and NHS Wales what we would consider to be an adequate in-year GMS contract deal for this current financial year. It didn’t match our reasonable expectation of an uplift of the contract value that would help counter the damaging impact of soaring inflation, practice costs and staffing expenses. This is a contractual negotiation, not just a pay award negotiation.

For health board salaried doctors, the offer on the table centred around the 5% GP pay award and a 5% staff uplift. And that proposed 5% award is sub-inflationary, below the 6% recommendation of the independent DDRB pay review body for doctors.

But specifically in Wales, it doesn’t reflect the loss of compounded income due to the exclusion of GPs from the additional pay awards from 22/23. And if the offer on the table is just a pay award announcement, it doesn’t consider the additional asks from Welsh Government or NHS Wales in terms of additional service requirements to the contract.

You know, I’m always very clear in any discussions, any negotiations, that a shift of cost needs a shift of resource to actually cover that service change. So, without appropriate uplifts for both staff pay rises and a rise in general expenses, any GP pay uplift is immediately eroded as the contractors would have to fund the shortfalls of the expenses directly. So any realistic GP pay award has been diminished.

In real terms, the proposal on the table is simplistically – far more complicated in reality – but the proposal would see GP partner income drop by the equivalent rate of inflation. And the Welsh Government cannot expect us as GPs to be providing more for less.

Q: What are the next steps – how can you move forward if you haven’t agreed a contract?

A: In the absence of a negotiated agreement, the contract could be forced upon surgeries and could be imposed. The Welsh Government has never forced through a whole contract imposition. But there are precedents in other parts of the UK. The minister also suggested the possibility of the current financial offer being withdrawn to offset NHS Wales financial deficits. And we have been absolutely clear that that would be devastating for general practice in Wales and would trigger an exodus from the profession that would be absolutely actively damaging to patient care in Wales. 

Having no contract deal, so a 0% uplift, would be devastating. The nuclear option of actually withdrawing funding from GMS to offset other NHS services would be absolutely crippling, to the NHS in Wales as a whole.

So we still hope that there can be a realistic contract uplift that can be negotiated and we remain open to further discussions with Welsh Government, should they have a credible new proposal that provides security and sustainability for practices and patients and patient services alike – inaction isn’t an option if general practice in Wales is to survive.

Q: What is GPC Wales seeking from negotiations?

A: That’s something that has to remain at the table as part of our internal strategy. Otherwise, we’ll lose all of our levers. But GPC Wales set out a rescue plan for Welsh general practice in June – the ‘save our surgeries’ report. It highlighted in a nutshell the fundamental issues of decreasing workforce, increasing workload, deteriorating wellbeing.

And the calls from that campaign are the fundamental tenets of our negotiating strategy – to commit to funding general practice properly, invest in the workforce of general practice, to allow safe and high quality service delivery, producing a workforce strategy in Wales that will train, recruit and retain, and to address the staff wellbeing issues. And so with regards to long-term aims of negotiations, we would be looking to follow those basic principles. 

Of course we recognise that the Welsh Government has limited budgets nationally as a devolved nation. But it actually comes down to not that they haven’t got funds, it’s how they politically choose to spend those funds, and where they wish to spend those funds within the NHS.

Q: What will GPC Wales do if the Government doesn’t come back with a credible offer? 

A: We are in a phase of political engagement, and public engagement, raising the issues. We’ve launched a letter writing campaign to members of the Senedd from our grassroots GPs. Already in three weeks we’ve delivered over 1,000 letters sent to Senedd members and I think that in itself demonstrates the power of unity and the support from the wider profession.

And of course, what will come from that is GPs organising practice visits with their local politicians to raise their individual concerns – real-life examples of the pressures that a non-contract agreement will place on the already apparent pressures of the chronic underfunding of the NHS in Wales. 

We do have cross-party support – this is the irony, is that we have cross-party support for the aims of our ‘save our surgeries’ campaign. That needs to be realised in the support from the Welsh Government with regards to the contractual negotiations.

Q: Will you consider industrial action?

A: Industrial action itself is difficult for independent contractors, more so than for salaried doctors. And if we just use the analogy that in Wales, the 5% pay offer for secondary care doctors has already been imposed by the Welsh Government after being rejected by the BMA. And the Welsh junior doctors are currently in a ballot with regards to industrial strike action. So, what next? 

We have an internal negotiation strategy. And I wouldn’t like to divulge the ‘what next’ because I don’t want to remove the levers at the table at the moment. We are in the lobbying and engagement process.

But I think the profession should be aware that GPC Wales and our executive are highly aware of the options that would be available to us and working through those options. And the desirability, the impactful-ness of the options available. And as and when it’s appropriate, we will announce those to the profession.

Q: Are you worried about practice closures and contract hand-backs in Wales?

A: Our BMA analysis shows that 84 practices have closed in the last 10 years, and five have handed back their contracts in the last six months. So I feel that we are seeing an increasing trend. I certainly know that from conversations and roadshows around the LMCs that many practices are continuing to review their viability and had been expressing those concerns prior to these contractual negotiation announcements – but I think that without a resolution, it will accelerate that. 

We’ve revamped our guidance for practices considering handing back their contract. It would be a major life-changing decision for many GPs, if they were to hand it back. They need to be aware, and take professional advice, accountancy advice, legal advice, with regard to closing down a business. You don’t just shut the doors one day. There should be a lot of consideration prior to that, if that is the ultimate decision that practices and practitioners need to make.

Q: Has the Government responded to any of your calls in the ‘save our surgeries’ campaign?

A: Lots of the issues fundamentally relate to funding and funding shortfalls, and there needs to be investment in workforce to actually match many of our requirements. But one of our calls was a workforce strategy, and there is a piece of work from Welsh Government and Health Education and Improvement Wales (HEIW) with regards to a primary care workforce strategy, which hasn’t yet been published, but is in evolution. 

Q: Will that have funding attached to it?

A: That’s the million dollar question. No, I don’t believe it does. A strategy without funding could be left on the shelf gathering dust. 

We would probably say that against the OECD average, we estimate the need for an additional 660 GPs in Wales. That is the deficit, but there needs to be financial backing to actually allow that to happen in a sustainable, resilient fashion. 

Q: The BMA recently raised the issue of the Welsh Government overspending on health-board managed practices – what do you mean by overspent?

A: What we’ve identified through a series of freedom-of-information requests, was that the actual spend by health boards on their managed surgeries is over and above that which would have been spent through a global sum allocation to an independent contractor. We did it on a per-capita basis, and found that the cost of delivering the same services for general practice through managed practices was around a third greater than the GMS equivalent payments. 

To a certain extent, that’s because health boards are required to employ their staff in different ways, with agenda for change terms and conditions. And they probably use more locum GPs to fill the gaps left by not having GP partners, recognising, of course, that salaried doctors would have probably workload caps within their contracts. Whereas the independent contracting partner is contractually there to see as many as come through the doors, or as many people that are needed to be seen. 

So the efficiencies of the independent contracting model with regards to financial requirements are clear from our analysis. And there’s another example – over the last two years the Welsh Government has funded some pilot schemes to the health boards to provide urgent primary care centres. Health boards have done their own analysis that has actually shown that these centres are probably offering an appointment costing 50% more than an independent contractor. The centres probably see a certain cohort – they’re not seeing unfiltered or complex presentations, they’re not providing continuity.

So I think the cost of both the managed practices and the urgent primary care centres actually show the efficiencies of the model. They might, of course, identify the underfunding of the independent contractor model. But there’s more complexities to it than that. So I wouldn’t like to jump straight to that. What we would call for is a proactive support for struggling practices. And even for the money that is being spent on urgent primary care centres to be spent directly into GMS practices – value for money.

Q: How do you see issues play out at your own GP practice?

A: My practice is no different from any other practice, we’re not divorced from the implications of increasing workload, as well as the post pandemic changes to the way that we work and moving towards a hybrid telephone-first model. My particular surgery has expanded because of closures of neighbouring practices and dispersal of patients. My building’s no bigger, but I’ve got more patients.