Pulse summarises July’s talking points – what will the BMA ballot change, and what has the new health secretary done in his first month
How will the BMA ballot change the landscape of general practice?
Limbo. Purgatory. In-between. Precipice. Call it what you want, but we’re in it right now. The GPCE ballot on collective action shut at midday yesterday and the final results have yet to be called. While we don’t want to incorrectly pre-empt the results, it is likely that partners will have voted ‘yes’. This means that, according to the original timeline, GPs would be starting collective action as soon as Thursday.
For many, this has been a long time coming. Long term, this is the result of years of underfunding and damaging policies. The fuel that lit the flame though was the 2024/25 imposed contract offering a measly 1.9% uplift. In a ‘temperature check’ ballot held in March, 99% of BMA registered voted ‘no’ to accepting the changes offered by NHS England. Since then, it has been a slow but steady path towards this moment.
Given the unique structure of the partnership model, it will be interesting to see how this rolls out. The GPCE has laid out a menu of actions from which practices can pick and choose how they engage. None of these include a breaching of contracts, but rather dialling back work that GPs automatically do which they are not contractually obliged to do. Examples are: limit patients per GP to 25 a day; stop engaging with the e-Referral Advice & Guidance pathway; stop rationing referrals, investigations, and admissions etc.
Allowing practices to pick and choose their actions is understandable; every practice is different in terms of staffing, population size and needs. But, if some practices engage in all nine listed options and others only do one, then how united a front does it present? Online, some GPs have voiced that many practices already don’t engage with several of the options meaning that their contribution – if any – to collective action will be muted.
And most importantly, if these actions are non-contractual, then why don’t those practices under pressure (ie, all of them) refuse to do them at all times?
Additionally, the turnout of the ballot will be revealing too. On Friday, GPCE rallied for a final push in votes, to ‘secure essential leverage.’ There had only been a 59% turnout of eligible BMA member voters which was below the minimum threshold required (60%) if it was a formal postal ballot for industrial action. Given that this is a non-statutory ballot and none of the actions suggested will breach the contract, the threshold doesn’t need to be met. However, a low turnout will obviously significantly weaken the GPCE’s position in any forthcoming negotiations.
And although industrial action hasn’t started, or even been voted through yet, we have already started to see tension from GP action. NHS England’s only GP board member Professor Helen Stokes-Lampard commented that some GP practices had already started ‘pulling back’ from discretionary work.
At the beginning of the month, GPCE accused NHSE of trying to frustrate industrial action. One of the original proposals in the ‘menu of actions’ was to switch off GP Connect functionality which allowed for third-party providers to code into GP clinical records. However, this was expedited at the beginning of the month at the recommendation of the GPCE after it found out that NHSE was making moves to prevent the functionality being turned off. GPCE chair Dr Katie Brammall-Stainer instructed GPs over the weekend to turn it off before NHSE made it impossible to do so. NHS England denied that they were trying to upset any impending industrial action, but their denial was at odds with TPP’s statement which said that NHSE had reached out to them to remove the third-party coding functionality.
So in terms of what the BMA ballot will change, it is a mixed bag. For GPs it may feel minimal, or incremental at the very least – many have already been pulling back from discretionary work and others never did it as it did not form part of the contract. But, the external impact is where it will be felt. Many national outlets have focussed on the statistic that this will be the first time in 60 years that GPs have engaged in industrial action. One might hope that this will show patients how dire the situation is, but knowing their luck it will only exacerbate anti-GP sentiment. NHS leaders have warned that the impact of collective action will be catastrophic on A&E and cause the whole health service to come to a standstill. Perhaps this will serve to show the NHS and patients how integral GPs are and how much extra work they do every single day.
How has the new health secretary fared in his first month?
It has been just under a month since Wes Streeting was crowned as the new health secretary, voted in by the very skin of his teeth we might add.
Streeting and GPs have a storied history. As shadow health secretary he made waves last January by saying that if elected he would get rid of the ‘murky, opaque’ GP contract and heavily consider abolishing the partnership model to move towards a salaried service. Ten months later he admitted that he did understand the value of the partnership model and would not seek to remove it if elected. In the months and weeks running up to the general election, he promised that general practice would ‘do well’ and had ‘a lot to look forward to’ under a Labour government – hinting at funding increases, but the manifesto stopped short of promising any increased investment.
One can’t say that Streeting hasn’t had a busy first month in the job: he announced he would defend the previous government’s emergency ban on puberty blockers following the Cass Review; he negotiated a pay offer with the junior doctors’ BMA committee; and he professed shock and disappointment with the findings of an independent review of the CQC, vowing to take steps to address the issues.
Streeting has, at least optics-wise, sought to make general practice a priority for him and his team. His decision to have his first official visit as health secretary to a GP practice in London was welcomed by many. In that visit he committed to ‘reversing’ the underfunding of general practice, but these details remain shrouded, although he has mentioned previously that any funding would be done incrementally.
Many compared the Labour landslide to that of 1997, and it seems Streeting has also taken inspiration from that period too, by bringing back two Blair-era politicians. Alan Milburn, former Labour health secretary, has been brought in to help Streeting reform the NHS. Given that Milburn was responsible for pioneering increased private involvement in the NHS, to have him on board is an… interesting choice.
Professor Lord Ara Darzi, former Labour minister, has also been summoned onboard by Streeting to lead an ‘independent investigation’ into the state of the NHS. He and former policy director of the King’s Fund think tank Sally Warren have been tasked with drawing up a 10-year plan based on the findings of their investigations. The pair have only been given six weeks to fix our ‘broken’ NHS, which is great, because as everyone will agree, it is far easier to put toothpaste back in the tube than it is to squeeze it out in the first place.
One might think that Lord Darzi’s appointment might have triggered more detail on Labour’s plans for ‘neighbourhood health centres’ of manifesto fame, given the similarities drawn between them and Darzi’s polyclinics of the early 2010s. However, anyone interested in that will be sorely disappointed – as will anyone keen to see if other manifesto points have been addressed. The promise to train ‘thousands more GPs’ remains vague. Almost 10,000 GPs signed an RCGP open letter asking for an urgent review of the NHS long-term workforce plan which only planned to increase the number of fully qualified GPs by 4% by 2037. Pulse’s own analysis has determined this woefully inadequate and that ‘training more GPs’ requires more trainers, better infrastructure and property to do so. Though Streeting did address the ‘absurd’ truth that GPs are struggling to find jobs, there has been little else said about the employment crisis, one of – if not the – biggest issue facing the profession. There has also been no mention of the other significant challenges facing general practice: ARRS, industrial action, physician associates.
Perhaps it is too much to ask one man to do so much in only one month. To give Streeting credit, he has devoted time and energy to trying to understand the landscape of general practice. His message on X to a GP partner in Surrey was stark in its humanity and empathy, and at the very least showed a desire to work together, which is more that can be said of the previous government.
I’m interested how a key feature of GP industrial action is to ‘stop rationing referrals, investigations, admissions’.
As a GP, I have never rationed any of those resources, and to do so would be immoral, contrary to GMC guidance, and a breach of GMS contract.
I have, however, advised patients when a referral, admission or investigation was not necessary, and might be harmful or pointless, and will continue to do so. Wasting scarce NHS resources would be equally bad. But I have not undertaken ‘rationing’, and I doubt if GPs have done.