Helen Salisbury: GP collective action to end unfunded work

Many GPs are not only cross and tired: they’re genuinely worried about the future of their practices. The amount of money available to run a surgery hasn’t kept pace with inflation, and we need a 10.7% rise in the value of the GP contract to restore funding to 2018-19 levels.1

More than two thirds of GPs who were eligible to vote took part in an indicative ballot recently, and 98.3% voted for collective action.2 The actions available to GPs to express their anger and dissatisfaction with the latest contract imposition are quite different from the strikes that our colleagues in hospitals have held with such positive results. GP partners hold contracts with the NHS, and if we withdrew our labour we’d be in breach of contract and would be fined or lose our income entirely.

Even if we were able to strike it’s not clear that GPs would do so, as our position in our communities and the connection to our patients makes this very difficult. So, instead of industrial action, what’s been proposed is “collective action,” which will focus on GPs stopping doing the things they’re not paid to do. There’s a list of 10 possible actions, most of which are forms of non-cooperation with NHS England—designed to frustrate the organisation rather than affect our patients. These include refusing to engage in advice and guidance (A&G) systems before referral (unless we choose to); writing old fashioned referral letters rather than filling in proformas (excluding cancer referrals); refusing to ration referrals or investigations; and non-cooperation with NHS England data collection.

The suggested action that will affect patients is that of limiting the consultations undertaken by each GP to 25 a day. This is a consensus figure about what constitutes safe working from primary care doctors throughout Europe.3 This means safe for doctors (as taking on more than this increases the risk of error and burnout) and safe for patients (as this level of activity gives a much better chance of a thorough consultation that sorts out the problem). In many places GPs regularly see more than twice this number, and although it’s unlikely that surgeries will impose this strict limit straight away—especially in areas that lack alternative provision, such as urgent care centres—this is what we should aim for.

Modelling of the impact of GPs “working to contract” has been produced by NHS England and leaked to the Health Service Journal.4 In the most pessimistic scenario it calculates that a 30% drop in GP activity would cost £570m and generate half a million extra referrals over four months.

This may be a realistic estimate of the value of the discretionary work that GPs currently undertake: it equates to an extra £1.7bn a year, which would be very helpful in paying our staff, employing more doctors, and keeping the doors open. With that money invested in general practice we could start to work towards a service with good access to GPs, enhanced continuity of care, and safer workloads.