Editor Jaimie Kaffash asks what action GPs could actually take after a derisory contract
I was going to write this editorial on the contract, but there is not really much to say. It is terrible (as we expected). The funding increase is insulting. The cuts to QOF bureaucracy is the mouldiest of carrots, focused mainly on disease registers, which take up barely any time for practices anyhow. There is nothing to help GPs here and I fully expect a 99%+ vote against the contract when it goes out to referendum this week. That’s about it on the substance (though you can read more here).
It was clear early on that the interesting aspect of these negotiations were always going to be what action the BMA would take in the aftermath. Our story yesterday suggested that the BMA was planning for potential industrial action in November. I believe that they will go through with this – GPC England chair Dr Katie Bramall-Stainer is serious about this.
I think everyone agrees something needs to be done. General practice can’t continue like this, and the Government can’t be allowed to just impose whatever terms it likes without real pushback. But my trouble with this is – as it has always been – around what GP industrial action would look like. It might be my lack of imagination, but I can’t see what action can be effective. Here are some suggestions – and what I think the drawbacks are.
Closing surgeries for a day/week. This is the most obvious form of action, but I can see so many downsides, without many upsides. On the plus side, it would get media and public attention. But even with GPs stopping urgent care as part of the action – and I’ve not seen much appetite for this – I can’t see it doing any good.
The Government are happily riding out long and sustained strikes by junior doctors, which has a far more obvious impact on the public than the closure of general practice for a day. Even ignoring the inevitable hilarious headlines – ‘GPs are on strike? I didn’t notice!’ – it would realistically take at least a week until action had a material impact on patients. If ministers are happy for secondary care to run at limited capacity for this long, they certainly won’t be spooked by GPs doing the same for a shorter time period.
On top of this, we can’t ignore the financial implications. Practices are already facing a funding crisis. They simply can’t afford a week’s non-payment – during which time their running costs will be pretty much the same. And in a similar vein, there is the technical complexity of trying to achieve strike action among a workforce which is split into two completely different types of employment – self-employed and employed.
Mass undated resignations. This has been used to good effect in the past. But in the current climate, this feels like an existential risk. As I argued last week, the Government has decided that ‘this’ll do’ is the standard they require. This includes having care traditionally provided by GPs to now be provided by physician associates and nurse practitioners. GPs resigning (or even threatening to) would give the Government an easy excuse to move to a cheaper nurse/PA/whatever-led service, with minimal GP input. True, this would lead to further deterioration of patient care, but I don’t believe the Government cares about this.
The other way this could go is general practice following the path of dentistry. Even apart from the fundamental ideological problems that many – including me – would have with this, I am not sure whether it will even benefit GPs. It is a leap into the abyss and it could lead to everyone being far worse off. Either way, I think such action would be have a worse effect for GPs than it would for this Government.
Refer everything. Another suggestion I have heard – from Copperfield among others – is referring everything to secondary care. This is an interesting one, but again I don’t think it has legs. It’ll piss off colleagues in secondary care, but patients will be unaware that they are being affected, and waiting list figures are bordering on abstract these days – a few million extra here or there won’t sway this Government.
Work to rule. The problem with this – or anything else that will reduce workload, such as diverting overspill to NHS 111, or restrictions on access – is that if these measures are achievable, they should be done regardless of industrial action. In some cases, practices are doing these through gaming the system (and good luck to them). But in most cases, practices simply can’t stem demand. And this is why industrial action is needed in the first place.
Wait for a change in government. Part of the problems with the above is that the Government has shown it doesn’t care about any deterioration in care. Would the Labour Party be any different?
We have no clue what Labour want. We know Wes passionately wants ‘better access to GPs, continuity of care, and making it easier to book appointments’. I, too, passionately want ‘things being good’. But they have given no indication about how they will achieve this.
Would they be more receptive to getting round the table with public sector professions? Maybe, but it would need to be a massive table, and for reasons above, GPs may not be first in line. They have extinguished any hope made realistic public spending plans, so expecting them to address the funding crisis in general practice might be foolish. It’s more likely they will take a similar line to the current government, but with a sympathetic smile and ‘what can we do’ shrug.
So what is left? Part of the reason I wrote this blog is because I want to hear from readers about what can be done. I’ll follow this up with other suggestions – send any to me at editor@pulsetoday.co.uk , or even in the comment section below. I trust this GPC to formulate a plan of action if there is a workable one. But right now, I not sure such a plan is possible.
Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at editor@pulsetoday.co.uk
READERS' COMMENTS [16]
Please note, only GPs are permitted to add comments to articles
Thank you for starting the conversation, Jamie.
My favourite would be “work to rule”, but it needs better branding and a bit of marketing. Worst that might happen is our workload will become manageable.
We could be in a perpetual work to rule IA until properly funded or when pigs fly, whatever comes first
“Doing a dentist”. Strikes won’t work as all we are doing is making things worse for ourselves by making the workload a week from now utterly miserable rather than the day-to-day firefighting. We are drowning in workload and a fee at the point of use is the only way I see to stem the tide. I appreciate that, on an ideological basis, this will not appeal to everyone, but I spend my days apologising for the state of the NHS and trying to paper over the cracks. We are about to split into a ‘free and see a PA’ vs ‘pay and see a GP’ service; that is clearly what is wanted by the government and I see no point in continuing to practice on the margins, with our necks in the noose if and when things go wrong.
Not sure!! How do we create impact.
I was thinking , stay open for chronic work only. Book in QoF reviews, all chronic work but essentially phones are off and no urgent work. But have to do this for 1 week. A day or 2 is not going to make a difference
We could also stop doing DWP forms, or fill in that they need to assess patients. There will be minimal impact.
I would counsel wait and see what the referendum says , what the government offer after DDRB reports in July and then what the BMA legal team have decided is possible under contract law.
BMA should not , and I guess will not, show their cards till after they have a legal mandate under trade union law.
First things first , see if GPs will unite to give a mandate to BMA to take things further .
But don’t show your cards too early, the government can always legislate to outlaw what may be planned .
Timelines suggest this will be for the next government to sort ( or not)
I have posted on this before. You have hit the nail on the head, what realistic options are there? This is why industrial action will fail. Contractors can not strike in any meaningful way.
You can dream of mass resignations etc, but get a grip, it won’t happen.
To work, this will require a leap of imagination that is beyond me.
Yes, despair at all other options or work to rule. But think it through – and it’s a win- win
IA might coincide with GE so unlikely to happen before a presumably Labour government, then settlement more likely.
As is, I’d prepare for undated mass resignations and taking back control (!). Partial concessions to IA primarily inconvenience patients, little effect, maybe cause some harm, and rapidly whip up a Govt-fest of adverse GP publicity. Mass resignations are technical and less impactful to patients.
Whilst abundant measures of distress across the NHS system have deteriorated to an extreme, patients have no voice and we’ve been ignored. Striking doctors have been driving some hard bargains to get fair treatment.
Once was a Red Book, now there’s NHSE.
The BMA should fully work up and distribute a credible plan for going dentist (a modern day “Guernsey” option). This should be paired with undated resignations and we should be willing to go through with it. The general public don’t understand quite how things are because a smaller number of GPs keeps pedalling fast and faster keeping the service going at the cost of their own sanity.
I would propose the following: closed doors except for pre- booked appointments, continue all booked in advance appointments with NURSES only (therefore we fulfill all obligations of phlebotomy LES, QOF, Extended hours etc) For DOCTORS max 26 appointments a day, no visits except nursing homes, all other visits, call an ambulance, 26 pre-booked appointments only with routine stuff, medication reviews, minor surgery, COILS, implants, procedures, paperwork, review of bloods, results, letters, etc, plus cover for nursing homes only to take the stress off OOH cover. Contract between all surgeries and OOH service and divert all urgent on the day appts, with this subcontract to OOH they cannot say there is no cover. Ideally coordinate this action for at least 3 working days, the longer the better.
JK’s piece sets out the difficulties of uniting 3 types of GP to agree a common course of action (confirmed by comments). This is exactly what HMG expects and will be laughing about.
So probably the best thing to do right now is to vote to give BMA GPC full authority. This’ll send a strong signal to HMG of our anger. Whatever action is eventually taken is a decision for later.
I support a combination of work to rule combined with reduced co-operation with NHSE /ICB/PCNs and via complete refusal to attend meetings or respond to any requests related to ICB/ /ICS/PCN and NHSE directives of any type which would both not harm patients and reduce workload and reduce the autocratic sometimes dictatorial like actions of these groups.
There should be total non-co-operation with PCNs/PCN Clinical Directors , the latter who will continue feathering their own nests with CD payments to the detriment of practices yet lead the destruction of Primary care at the behest of NHSE as has been seen with drastically reduced roles for GPs and in my view reduced quality.
Direct bypass lines to practices abused by ICBs and NHSE could be closed whereby other services equally under strain such as paramedics , social workers etc seek to use to offload off their own workload crisis to the bottomless pit of GP Practices. These patients would of course then need to be served by the organisation seeing them initially with no real risk to patients and then needing to raise their own workload concerns.
The ARR roles cannot be rescinded so payments would continue, and the work of general Practice would not be impeded by wholly useless meetings with PCN Clinical Directors and ICB Implementation managers showing off their latest multi-coloured charts often showing their beloved downward trends to further hammer GP Practices that they themselves have wrecked via obtuse and ill-considered NHSE/ICB/PCN policies
The contractual need to direct patients at first call to appropriate services which often do not exist should be rejected.
The Government and NHSE machine denigrating General Practice which has led to the negative public perception of General Practice relies on data and we could refuse now to submit multiple forms of data (many GPs may not be aware of the voluminous extent of data and requests) sent mainly by practice managers to NHS England e.g. workforce data, appointment data etc etc.
We could refuse and reverse the need to submit align appointment slots to appointment type and revert all appointment slots back to non-monitored appointments . The reason for this is that the data already shows increased GP workload and attainment but the government NHSE has ignored this in the argument for increased resources and used this for its own political purposes to state they have increased access without stating this has been done by Primary care without adequate resources.
Additional ICB/NHSE campaigns could be refused ongoing.
We cannot close GP practices without a huge backlash related to the scurrilous negative Government/NHSE publicity machine against GPs.
However, all extended GP practice hours and HUBs could be refused and declined with some modification and thought.
The ethos of the above is that we know how to run General Practice and with an industrial action trend showing what we can do in spite of an ineffective RCGP and without the PCN/ICB/NHSE and Government ball and chains stifling progress and innovation we can turn industrial action into a revolution for positive change.
We cannot do anything which reduces services to patients. I believe the government’s intention is precisely to goad us into striking, further diminishing our currency with the public, so carefully crafted since Covid by their proxies in the media. What we can do is to refuse all activity which is not direct care to the patient. Appraisal, CQC, All non face to face appointments, all work transfer from hospitals, all reports, all non-clinical meetings. All referrals by letter, no time-wasting pro-formas. We’ll have more time, patient care will improve. Please, let’s make sure we punch up and not down.
GPs are a disparate rag-tag bunch of partner/salaried/locum doctors. We are an uncoordinated rabble incapable of unified Industrial Action, as the farcical pensions “strike” amply illustrated, and governments know it.
So, sorry to pour scorn on the excellent ideas above, but they are all doomed to fail. In any town, Surgery A will be on strike, B might refer everything, whilst C and D will be business as usual.
My suggestion is that we brandish the 2% as a weapon to whip up public sympathy. Posters plastered over surgeries, hand-wringing media articles, Patient Participation Groups empowered to lobby MPs, and decrying every handed-back contract as evidence of Primary Care collapse.
This would then become a major issue in the forthcoming election, with parties competing in promising how much they will invest in General Practice, hopefully leading to a genuinely game-changing favourable 2025 contract, similar to 2004.
I’m just waiting for the thud.
Looking forward to watching the BMA try this; hopefully the resulting fiasco will make it clear to all but the most intransigent that the BMA is long overdue a discreet funeral, no flowers necessary.