Collective action is the big story in general practice in England this summer. But, despite the headlines, there’s been no ‘big bang’ moment – instead, we’re seeing a slow but steady change to the way general practice works. Eliza Parr looks at what the action means for GP practices. Please note, this article will be constantly updated.
Is ‘collective action’ a strike?
The BMA has been very clear that collective action at this stage is not a strike – no practice will be shutting its doors. Instead, GP leaders have called it a ‘lifestyle modification’. The ballot held by the BMA was ‘non-statutory’, meaning that any actions the union directs GP partners and their staff to take would ‘not involve contract breaches’.
According to the union, GP partners are ‘in dispute’ with the Government but there are no current plans to strike. This means the collective action as it stands ‘does not amount to industrial action governed by the Trade Union & Labour Relations (Consolidation) Act 1992’.
Why are practices taking action?
Just over 98% of GP partners voted ‘yes’ to taking collective action in the ballot, which closed at the end of July. But the dispute actually started earlier this year. In a ‘temperature check’ of the profession in March, GP members overwhelmingly voted not to accept the Government’s imposed contract changes, which lifted core funding by 1.9% (which has since been lifted to 7.4% overall). The GP Committee England then wrote to NHS England to confirm that they are ‘now in dispute’.
GP leaders have said that the aim of collective action is to ‘turn up the pressure on the Government’ and get ministers ‘back around the table to negotiate in good faith with the GPCE’. The goal is to negotiate a ‘new contract’ in England which ‘provides the investment needed to transform, rebuild, and reinvigorate general practice’.
Humberside LMCs chair Dr Zoe Norris says practices ‘are just fed up’ and feel they ‘haven’t got another choice’. In the past, she tells Pulse, GPs may have been ‘optimistic’ and believed the situation will ‘improve’.
‘But the difference this time is that they’re prepared to act to try and safeguard their patients […] the goodwill has just been eroded to such an extent that something has to give,’ Dr Norris says.
What action is the BMA recommending?
Unlike a strike – which usually involves one decisive action – GPs can pick from 10. The BMA has published a ‘menu’ of options from which GPs can implement one, several, or all 10.
A principle driving all of the actions is that GPs should be working safely and within their contract. There is no prescribed order practices should follow, as the GPCE has been clear it ‘is not recommending which action(s) practices take’ – they can ‘pick and choose as they see fit’.
BMA menu of actions
- Limit daily patient contacts per clinician to the safe maximum of 25. Divert patients to local urgent care settings once daily maximum capacity has been reached.
- Stop engaging with the Advice and Guidance (A&G) pathway – unless for you it is 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 via eRS or two-week wait (2WW) appointments, but outside of that write a professional referral letter in place of any locally imposed proformas 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 ICB for the purposes of system financial savings and/or rationing.
- Defer signing declarations of completion for ‘better digital telephony’ and ‘simpler online requests’ until further GPCE guidance is available. In the meantime:
- Defer signing off ‘better digital telephony’ until after October 2024: do not agree to share your call volume data metrics with NHS England.
- Defer signing off ‘simpler online requests’ until spring 2025: do not agree to keep your online triage tools on throughout core practice opening hours, even when you have reached your maximum safe capacity.
- Defer making any decisions to accept local or national NHSE pilot programmes whilst we explore opportunities with the new Government.
Source: BMA
What are the risks to practices?
GPCE leaders have emphasised time and again that all of the actions are ‘already permissible’ and ‘will not result in a contract breach’. Unlike employed doctors or nurses in other parts of the NHS, GP partners are independent contractors which makes any form of industrial action slightly more complicated. But the BMA has previously taken legal advice which found that independent contractors can take industrial action.
And of course, GPs have taken action in the past – in 2012, the BMA held a doctor-wide (albeit unsuccessful) strike over pension reform which included GPs. And in the 1960s, thousands of GPs submitted undated resignations to the BMA which gave the union leverage to negotiate the ‘GP charter’, enacted in 1966.
Collective action in 2024 is a little different. The BMA’s recommended actions involve GPs ‘working to rule’ rather than walking out. But practices taking part should be aware that their ICBs are monitoring the situation.
Earlier this month, NHS England instructed ICBs to ensure practices are continuing to meet their contractual requirements during collective action. According to NHSE, practices must ‘be able to assure their commissioners’ that they are ‘continuing to meet the reasonable needs of the patients’.
Will it harm patients?
Collective action has made national headlines in recent weeks, as NHS leaders warned that it could have a ‘catastrophic’ impact on A&E and other services. Indeed, GPCE chair Dr Katie Bramall-Stainer has said herself that GPs working within their contract will ‘bring the NHS to a standstill’.
It seems inevitable then that such a large impact on the NHS system will have knock-on effects for patients. But Dr Bramall-Stainer has repeatedly said that ‘patients won’t come to harm from this’ and that the action is instead directed at NHS England and the Department of Health and Social Care (DHSC).
Some GPs, it seems, disagree. In Pulse’s recent snapshot survey, a quarter of GP partners said they believe collective action will increase patient harm in the short term, while a fifth said the same for patient harm in the long term. (There is also the point of view – put forward by Copperfield – that any action should be harmful, if it is to have any effect).
Many GPs say that collective action could have a net positive effect. Almost half of GP partners responding to the survey said action now will decrease harm to patients in the long term.
Who do you need to inform if taking part?
The BMA confirmed to Pulse that there is no contractual obligation for practices to inform their ICB of any action they are taking. The union also pointed out that ICBs have had plenty of forewarning about GP collective action. Back in April, the GPCE alerted all 42 ICBs of ‘significant risks’ which may arise from potential action by GPs later in the year.
However, NHS England has previously indicated that practices need to notify their ICB under certain circumstances. For example, if capping patient contacts to 25 per day, practices will likely need to divert patients to 111 or other services. In the primary care recovery plan, published last year, NHS England made clear that practices should only do so ‘in exceptional circumstances’ and should inform their ICB.
On this action, Derby and Derbyshire medical director Dr Ben Milton warns against implementing it too hastily. ‘Something like the 25-contact cap, done badly and done in a bit of a hurry and not well communicated, risks your patients being up in arms. And you risk your ICB coming and tapping on your door saying “what’s all this going on at 111?”’
The BMA has said there will be more guidance on the collective action, which will hopefully clarify what practices need to do.
What about salaried and locum GPs?
The BMA’s non-statutory ballot included only GP contractors and partners, as they will lead any collective action. New guidance from the union clarified that salaried and locum GPs must follow the lead of their employing partners.
Any sessional GPs who take part in collective action without instruction from their employer could be in breach of their own contracts and face disciplinary action. On the flip side, sessional GPs must follow instructions from the practice partners who are taking part, even if they themselves ‘do not want to’.
The union urged GP partners to communicate clearly to sessional GPs if they have to change ways of working, such as by capping patient contacts or stopping engagement with A&G.
However, some of the actions would not involve or impact salaried or locum GPs – those concerning commissioning, pilots or signing off digital projects.
How many practices are taking part?
Pulse’s survey of 283 GP partner respondents from different practices – representing 5% of practices in England – found that almost half (46%) of practices are taking some form of collective action.
A further 20% said they will be taking collective action in the future, with a further 22% said they were considering it. This means only 7% seem to have no interest in collective action whatsoever. This tallies with the GP partner response to the BMA’s ballot, in which they overwhelmingly voted in favour of action.
LMCs tell Pulse that many practices are still considering what action to take, with Derby and Derbyshire’s Dr Milton saying that ‘a lot of people are really nervous about it’ while many are also away during the school holidays. Wessex LMCs joint CEO Dr Laura Edwards says this is ‘a marathon and not a sprint’.
South Staffordshire LMC chair Dr Manu Agrawal tells Pulse that capping patient contacts ‘is coming across as quite popular’. Pulse’s survey suggests that over a quarter of practices have already started implementing this action, while just under a half are considering it.
Another seemingly popular action is switching off the GP Connect Update Record functionality, with the survey indicating that two thirds of practices have already done this. At the end of June, the GPC told practices to urgently remove the GP Connect functionality ahead of the ballot result. This was based on claims that NHS England was attempting to ‘frustrate’ the action by removing GPs’ rights to control this – a claim which NHS England strongly denied.
While Pulse’s exclusive data offers early insight into the first two weeks of collective action, the BMA has said it will also capture insights on what actions participating practices are taking, and this data will be shared with LMCs.
How long will it last?
Unlike junior doctor or consultant strikes, there is no set time frame for GP collective action. But it’s clear that this is not a temporary measure – the BMA has said it is ‘not just for the summer’ and will continue until the Government ‘comes to the table and agrees a new contract’.
Since the actions are all within the contract, the union said that some ‘can be permanent changes’, whereas ‘others may be de-escalated following negotiations with the new Government’.
This message seems to have reached GPs. Pulse’s survey suggested that half (51%) of GP practices will take some form of collective action ‘indefinitely’, while only 2% plan to carry on for less than one month.
Will collective action escalate beyond the 10 actions?
Whether the Government does get round the negotiating table remains to be seen. On the eve of collective action, the Government announced that the Additional Roles Reimbursement Scheme (ARRS) would be expanded to include GPs. Health secretary Wes Streeting stressed that this is a sign the new Government listens to the profession and wants to help solve issues such as GP unemployment.
The timing of this announcement suggests that the Government does wish to make changes to avert collective action. But NHS England recognised that longer-term solutions are needed to address ‘GP employment and general practice sustainability’. And DHSC has said that these solutions would be ‘part of the next fiscal event’. GPCE chair Dr Bramall-Stainer has also hinted that talks so far with the health secretary and primary care minister have been ‘positive’.
But there is a ‘plan B’. The BMA has warned that if the Government does not listen to their ‘reasonable proposals’ for a fairer contract, there could be further action. This ‘could involve escalation to contract breach actions, e.g. action short of strike or strike action’. The union said this ‘may include’ other salaried staff members and GP trainees.
So far, the GPCE has not indicated when this escalation might take place. A previous timeline for industrial action was thrown off course by the snap election in July. But many GPs stand ready – Pulse’s survey suggested that half of GP practices would take part if the BMA decides to escalate action to breach contractual obligations. Just over a third (35%) of GP partner respondents said they ‘don’t know’, but only 15% ruled it out completely.
What is the ultimate goal?
The BMA has put a strong focus on providing ‘safety’ by urgently resourcing practices in this financial year, while also providing ‘stability’ with future funding commitments. Most immediately, the GP committee wants to return core funding to 2018/19 levels. Since then, they say the GMS contract has been eroded by £659m due to inflation. To counteract this, the committee pushed for a 10.7% uplift to the 2024/25 contract, which is below the 7.4% global sum uplift that has now been agreed to fund staff pay rises.
Dr Bramall-Stainer has also repeatedly called for a 2025 Family Doctor Charter, similar to the 1960s version brought in by the Wilson Government. This would include a ‘commitment to build up to a floor of 15% of NHS expenditure’ directed towards primary care.
Other asks for this financial year, outlined in their vision document, include an uplift to the Covid vaccination Item of Service (IoS) fee, allowing personalised care adjustment for childhood vaccinations, and resourcing a child and adult safeguarding DES.
Pulse's survey on collective action
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