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Debate: Should we close doors as part of industrial action?

Debate: Should we close doors as part of industrial action?

Following the GPCE declaring that it is ‘in dispute’ with NHS England over the imposed GMS contract, two GPs debate the pros and cons of closing our doors to patients as part of any potential collective action

YES: ‘Industrial action less than striking simply won’t work

When you think of industrial action, you think of strikes. They grab attention and headlines; the public implicitly understands what a strike is. Any form of collective action less than this will have no ‘public buy-in’ and therefore no ultimate effect on changing the system for the better.

For example, working to the BMA guidance of 25 patients a day would have no impact. Patients may be aware that it is even harder to access GP services, but besides that it will all just be business as usual. Other suggestions such as declining to refer – or delaying referral until after the strike – seem medicolegally fraught and unwise. 

Industrial action less than striking simply won’t work. As we have seen in other sectors, people withhold labour when in serious dispute because it works and forces an offer to be made, or at least negotiations to restart. Closing doors is the only way to strike effectively.

One canard is that patients attend A&E because they can’t see us. We deal with 90% of patient contacts with less than 10% of the NHS budget. I think it would be quite instructive to show politicians what happens when patients are actually all diverted away from primary care.

NHS general practice is drifting towards collapse, and this has been its direction of travel for many years. Indeed, I am regularly surprised that enough people keep pedalling more and more furiously to the point of breaking themselves to keep the system running.

The problem is that striking requires unity, and generally as GPs we are awful at this. During the pension strikes in 2012, many simply did not take part as they felt it was not appropriate. The rest saw ‘emergency’ cases but a patient assessment of an emergency is not the same as ours. 

We are in a caring profession because we want to help people. Suggestions such as not signing death certificates are met with winces at the thought of causing pain to already grieving families. For that same reason, there will always be a disunity towards striking from some colleagues because they feel, understandably, that anything affecting  patient care is a step too far. However, we are currently being prevented from caring properly for our patients. At present, we are simply firefighting without any capacity to plan for long-term change 

This country needs to have an adult conversation as to what can and should be funded for healthcare from general taxation, and something needs to force that discussion. Otherwise, we will continue to endure cut after cut until the system is effectively worthless and we end up with a system that offers only two ‘choices’: the NHS ‘go free and see a PA’; or the private ‘pay to see a GP.’

Ultimately, I see an item of service type funding being the way forward, whether some proportion is paid at the point of use, or whether our funding model changes. The current ‘all you can eat’ model is no longer feasible.

Striking, if we can get behind it, could at least ensure that there is some form of service for us and our relatives as we age. If not, the continual increase of pressure and demand will lead to no effective primary care service being available.

Dr Alexis Manning is a locum GP in Cardiff

NO: ‘Our actions should bring the profession together, rather than dividing it in two’

The derisory uplift offered by NHSE in the 2024/25 contract has angered general practice so much that it resulted in an almost unanimous rejection of that contract offer in the recent BMA referendum. Everyone agrees that something has to be done. This isn’t just about pay, but about workforce issues, workload management, and burnout too. Without intervention, there is a real threat of the GP model collapsing. So what should be our next course of action?

There has been talk of industrial action by GPs in the form of closing doors to patients. I wonder though, as do many, is it practical and realistic?

Closing our doors could result in breach of contract, and notices from ICBs to practices which partake in such strike action. Regarding the latter, when there was threat of strikes in June 2012, practices received letters from NHS England with potential consequences of closing doors including withholding of payments. In the end, only 25% of practices showed willingness in closing doors. 

For any action to be meaningful, it has to be taken by an overwhelming majority of members. Many practices, especially single-handed and small practices, will be very mindful of the potential impact that loss of contracts will have on job losses, redundancy payments, and mortgage payments. 

We need to be smart and take such actions that will make NHSE take notice but at the same time will not breach our contracts. Given that, as I am sure most will agree with me, GPs work beyond their contacts, it is very possible to take such action. And, as pointed out in their threatening letter to practices in 2012, NHSE expect the contract to be delivered in full.

Therefore, we should stick to our contracted hours only – completing all our work in those hours of 8.00- 6.30 Monday to Friday. If we are to complete all of our admin work (signing prescriptions, actioning pathology results, dealing with referrals etc.) during these core hours, then something has to give. That is where BMA safe working limits come into play.

We could also limit our patient contacts to 25 per day as per BMA guidance. A Pulse survey revealed that the profession sees an average of 37 patients a day. If we limited ourselves to this, then each patient could have a longer appointment and there would still be admin time for us during core hours. 

There are other possible alternatives that practices could take. Give notice to secondary care that we are ending any participation in shared care agreements on the basis of lack of capacity. Stop rationing referrals and have a low threshold in referring patients to secondary care. Stop doing work that is not part of the core contract or has LES commission. Consider a partial or full list closure. As a very last resort – undated mass resignations (which was very effective in 1996, 1974 and 2001.) 

We need to remember that our fight is against NHS England. Therefore, the impact of our actions should primarily be felt by them; not our patients, nor our colleagues. Shutting doors will only be effective if it is taken up by the vast majority of practices, which won’t happen if GPs will most likely receive ICB breach notices. Our actions should bring the profession together, rather than dividing it in two.

Dr Pradeep Bahalkar is a GP in Coventry



Please note, only GPs are permitted to add comments to articles

M M 3 May, 2024 8:28 pm

The answer is…

Work within safe limits (28) AND open the appointment list (up to 3 years ahead) as Secondary care does AND refer to 111 once capacity for urgent care has been reached – so no immediate danger for patients ever.

No downing tools. No “strike”. Just functioning the same as every single other part of the NHS works.

Keep seeing as many urgent/paeds as possible and all palliative care – but all routine work needs to be seen when there is an appropriate capacity to see them.

The waiting list will grow to incredible lengths within 2 weeks. Having to wait 10 months to speak to a GP about “x” will garner more attention/sympathy than any walkout.

Just my thoughts!

David Church 3 May, 2024 10:47 pm

MM makes avery good suggestion.
On the other hand, there is a lot of contract that can be complied with ‘in word’ and still disrupt.
What exactly is ‘closed door’? Is it that patient cannot get into building? Or that patient is advised by one of various methods to seek appropriate care elsewhere?
We are not responsible for ensuring that that ‘other care provision’ has capacity, and since we have been abused by patients turned away from secondary care by excuses of long waiting lists and failed IT, and strikes, it is now turn of secondary care to support GPs, and accept that GPs will not be able to handle ‘everything right now’, but we would be really happy if secondary care complains to NHSE about lack of availability of GP services, please.

win win 4 May, 2024 2:34 pm

Or all resign. But majority will not do that, the only option to get out of this stress is to leave UK .

Some Bloke 4 May, 2024 4:58 pm

it still baffles me how piss poor NHSE forward planning has been. to have situation where badly under- doctored country has thousands of unemployed GPs, Locums ready to travel almost any lenghts to secure shifts. They- NHSE- are responcible for this. And public need to hear that loud and clear.
I don’t believe this was part of a plan, just usual incompetence of UK healthcare bureaucrats. Their whole professional lives spent thinking that GP Partners will absorb all abuse, vitriol, insulting contract impositions, ARRS nonsence. Well,- no more. They have pushed and pushed and now we are standing with our back over clifedge and we have to push back or else we fall. Have to push back for our own sake but also for the sake of the future of healthcare in this country. Too important to be left to the imbeciles of NHSE and whoever is the health minister of the month in corrupt and sleazy tory party
Thinking how incompetent DOH and NHSE are, shouldn’t be that hard to outwit that lot.

So the bird flew away 4 May, 2024 7:02 pm

Dr Manning has laid out the rational and the moral argument. Strike or go dentist (which has more risks). Anything less and the public will have no idea about the crisis in GP. Anything less, as in Dr Bahalkar’s essay, won’t work and just smacks of GPs’ continuing collaboration with those dismantling the profession of general practice, looking after only your own income-earning interest or Stockholm syndrome.

Liquorice Root- Bitter and Twisted. 5 May, 2024 10:43 am

A locum GP is promoting closing doors .