GPs vote overwhelmingly to take collective action over contract
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj.q1717 (Published 02 August 2024) Cite this as: BMJ 2024;386:q1717
GPs in England have voted in favour of taking collective action over their contractual terms and insufficient funding for general practice. The action was announced by the BMA on 1 August after a ballot of GP partners asked about their willingness to take action in response to an imposed contract for 2024-25 that included a core funding uplift of 1.9%. GPs’ leaders have warned that the deal has already forced some practices to close.1
It is the first time in 60 years that GPs have taken collective action.
Actions could begin immediately, such as GPs seeing no more than 25 patients a day, refusing to share patients’ data “unless it’s in the best interests of a patient,” and switching off NHS software that tries to cut prescribing costs.
GP leaders said many of the actions would actually lead to GPs spending more time with their patients, while highlighting system failings in a bid to make the government take seriously general practices’ requests for extra support.
Other NHS leaders and analysts said the ballot result was a “watershed moment” but warned that a cap on GP appointments could be “catastrophic” for the healthcare system as a whole.
Some 8518 GPs in England voted in the ballot, of a total of 12 590 eligible voters (a turnout of 68%). An overwhelming 98.3% (8375) were in favour of taking part in one or more examples of collective action, from a menu of 10 options listed by the BMA, with just 1.7% (143) voting against. The ballot was held between 17 June and 29 July.
Katie Bramall-Stainer, chair of the BMA’s General Practitioners Committee for England (GPCE), said GPs’ clear verdict reflected “desperation” with the status quo.
“GPs are at the end of their tether,” she said. “For too long, we’ve been unable to provide the care we want to. We are witnessing general practice being broken. The era of the family doctor has been wiped out by recent consecutive governments, and our patients are suffering as a result.”
Bramall-Stainer said GPCE “understands that the new government has inherited a broken NHS” and said the committee had had some positive conversations with the new health and social care secretary about the situation in general practice. But she added, “Practices are still closing, so we have no choice but to move ahead with collective action to protect our practices and our patients.”
Kamila Hawthorne, chair of the Royal College of GPs, said the ballot showed GPs’ strength of feeling. “The current GP contract is failing to provide GPs and their patients with the support that they need and more resources are urgently required to tackle this.
After the BMA’s announcement, the health and social care secretary, Wes Streeting, wrote to GPs to say that he wanted to “reset the relationship between GPs and your government,”2 referring to his commitment to allow GPs in England to hire 1000 more doctors this year through the additional roles reimbursement scheme and his acceptance of the recommendation by the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) of a 6% pay rise for GPs and staff as “the first steps towards more sustainable general practice.”
What happens now?
From 1 August the BMA is encouraging practices to choose from a list of 10 actions (box 1), as few or as many as they think appropriate.4
The 10 actions the BMA is encouraging GPs to choose
Limit daily patient contacts per clinician to the European Union of General Practitioners’ recommended safe maximum of 25.3 Divert patients to local urgent care settings once the daily maximum has been reached. The BMA “strongly” advises that consultations be offered face to face.
Stop engaging with the e-Referral Advice and Guidance pathway, unless GPs believe it to be a timely and clinically helpful process.
Serve notice on any voluntary services currently undertaken that plug local commissioning gaps and stop supporting the system “at the expense of your business and staff.”
Stop rationing referrals, investigations, and admissions:
Refer, investigate, or admit patients to specialist care when it is clinically appropriate to do so.
Refer via eRS (electronic referral system) for two week wait appointments, but outside that write a professional referral letter in place of any locally imposed pro formas or referral forms, “where this is preferable.”
Switch off GPConnect Update Record functionality that permits the entry of coding into the GP clinical record by third party providers.
Withdraw permission for data sharing agreements that exclusively use data for secondary purposes (i.e. not direct care).
Freeze sign-up to any new data sharing agreements or local system data sharing platforms.
Switch off medicines optimisation software embedded by the local integrated care boards for the purposes of system financial savings or rationing (rather than the clinical benefit of patients).
Defer signing declarations of completion for “better digital telephony” and “simpler online requests” until further guidance from GPCE is available. In the meantime:
Defer signing off “better digital telephony” until after October 2024—do not agree to share call volume data metrics with NHS England.
Defer signing off “simpler online requests” until spring 2025—do not agree to keep online triage tools on throughout core practice opening hours, even when maximum safe capacity is reached.
Defer making any decisions to accept local or national NHS England pilot programmes while the BMA “explores opportunities” with the new government.
How will the actions affect patients?
Becks Fisher, director of research and policy at the health think thank the Nuffield Trust, said that, although the measures won’t amount to a full walkout, “any reduction in the availability or efficiency of general practice will have a major impact,” given pressure on the NHS. “This could mean longer waits to see a GP, more people going to A&E, and ultimately poorer care,” Fisher said.
Fisher added, “GP partners voting for collective action is a watershed moment for the NHS. Unlike other recent NHS staff strikes, this isn’t primarily about the pay of individual GPs.”
Gaurav Gupta, a GP in Faversham, chair of the Kent Local Medical Committee, and a BMA council member, who voted in favour of collective action to ensure safer conditions, said that general practice “was on its knees” amid high staff burnout rates and rising practice bankruptcies. He told The BMJ, “None of the things we are suggesting are going to have an immediate or acutely detrimental effect on patients. All we are asking for is a safe working environment.”
“Patients might find the changes difficult to navigate, but it is for the long term benefits of patients and the NHS.”
Hawthorne said, “Whatever actions practices take will have an impact . . . We urge the government to intervene and come to a resolution that is fit for purpose for patients and the GP teams working harder and harder to provide their care.”
Are GPs who take action at risk of breaching their contract?
No, said the BMA in its guidance, which advises GPs: “You can choose to start slowly and build incrementally or do all of them from day one as you wish. You do not need permission to do any of these actions. They are already permissible and will not result in contract breach.”
What might lead to the action ceasing?
The BMA hopes the action will help persuade the government to “fix” the problems with the 2024-25 national GP general medical services (GMS) contract, which GPs voted overwhelmingly to reject earlier this year.5
The BMA has welcomed the government’s commitment to accept in full the DDRB’s recommendation for a 6% pay increase as a “step in the right direction.”6
But Bramall-Stainer said that GPs still had hundreds of millions of pounds less in resources to run practices than even five years ago. “This will not be a ‘big bang.’ It will be a slow burn. It’s likely that the impact may not be felt for some time. We hope this will give the new government time to consider our proposed solutions, including fixing our contract once and for all.”
How have other health leaders reacted?
The NHS Confederation said it was “disappointing” that GPs were opting to take “drastic” steps in pursuit of a fair funding deal and urged GPs and the government to “work together to find solutions to avert this action in the interest of patients.”
Its chief executive, Matthew Taylor, said, “Those actions that will have a direct impact on patient care, such as limiting the number of appointments, could also have a catastrophic effect on the entire healthcare system. General practice is now supporting more patients than before the covid pandemic, so any reduction in their activity will put more pressure on, for example, A&E departments and waiting lists for treatment.”
The Patients Association also urged both parties to settle the dispute as soon as possible. A spokesperson said, “Patients can’t afford to be caught in the middle of this conflict, over which they have no say or any control. As practices begin taking action, it is crucial they clearly communicate any service changes to patients and provide clear and up-to-date information and guidance on accessing care.”
What does NHS England say?
The NHS is asking the public to still come forward as usual for care and attend appointments during the collective action by GPs, as practices will remain open.
Amanda Doyle, the national director for primary care and community services, said that NHS teams had worked hard to plan for disruption and to mitigate the effects of the action to ensure services continued.
“We will continue to work with government to find a resolution and end collective action,” Doyle said.