Following Pulse’s snapshot survey on collective action, we analyse the full set of data to see what it tells us about the current climate and what could happen next
Ever since NHS England’s imposed 2024/25 contract for general practice was rejected by 99% of GPs in a BMA referendum, we have been slowly walking along the path towards collective action. Five months later, we have finally reached the point of said collective action and can start to see what this actually looks like in practice. A Pulse survey of GP partners and principals has provided exclusive data into where we are a week or so after collective action officially began.
Is your practice engaging in collective action, or considering it in the future?
Almost half (46%) of England’s GP practices are taking some form of collective action, with 20% saying they will engage with it in the future. Only 7% firmly said that they would not engage in collective action.
Collective action was set to begin on Thursday 1 August following the closure of the BMA partner ballot that Monday. However, as repeatedly pointed out by the GPCE, none of the proposed actions breached the core contract and were ‘already permissible’ pre-ballot. In fact, before the ballot shut there were reports that GPs ‘pulling back’ from discretionary work was already starting to be felt in the NHS. Our data shows that of the 46% of practices currently taking part in collective action, half of those were already doing so before 1 August.
Which actions are you already taking, or considering taking?
The ‘menu of actions’ consists of 10 different options that practices can carry out as part of collective action. Our survey shows that the most popular action already being carried out by practices is switching off the ‘GP Connect Update Record’ functionality (65%). This is most likely due to the GPCE's recommendation for practices to turn off this function at the beginning of July, after it was found out that NHSE was making moves to prevent the functionality being turned off - a move accused by the GPCE of trying to 'frustrate' collective action.
This was followed by stopping the rationing of referrals, investigations and admissions (45%), and freezing sign-up to any new data sharing agreements or local system data sharing platforms (37%). Regarding future actions, 52% of practices said that they are considering serving notice on any voluntary services currently undertaken that plug local commissioning gaps.
Derby and Derbyshire medical director Dr Ben Milton notes that since collective action began, he has seen colleagues become a lot more ‘militant’ about the workload shift from secondary care. He adds: ‘Certainly, what I'm picking up in terms of communication with GP colleagues, is that probably the collective action, the ballot result, has emboldened colleagues who were already talking a lot about interface issues, it has emboldened them to make a much firmer stance on it.’
More than a quarter (27%) of all practices said they were limiting the number of patient contacts to 25 a day, and a further 44% said they were considering whether to do so. One GP said that their practice had currently capped the numbers they deal with on call to 30 per day, but that they ‘still take urgent vulnerable requests on top of this so more like 40 contacts per GP per day.’ They added: ‘This would only be if you were the doctor on duty all day – mostly we have one duty surgery (maybe about 20 patients) and then a booked surgery (13 patients). But now and again we get “double duty” and this is when it could be 40 patients.'
For how long are you considering taking any form of collective action?
There is no current ‘deadline’ for the end to collective action. The approximate timeline first put out in March was thrown off by an early general election, but there was no set indication of what time period collective action may last. At the opening of the ballot, the GPC indicated that this would be a continuous movement: ‘It’s not a strike, it’s not a crash diet, this is more a lifestyle modification. It’s going to continue this way; it’s not just for the summer. It is until the next Government comes to the table and agrees a new contract that is safe for GP partners, their practices, and their patients.’
The majority of practices are in agreement with this sentiment, with 51% saying they are prepared to engage in collective action indefinitely. Humberside LMC chief executive Dr Zoe Norris believes that collective action should ‘absolutely’ be permanent. She says: ‘I think what we're seeing is a step change in how modern general practice is delivered. I think that's going to continue unless we have a new core contract, which is what GPC England is asking for, because it's not viable to continue working in this way. It has left us with no choice, really, but to try and safeguard the care that we can deliver to the best standard possible, given the lack of funding and the lack of focus on general practice over the last decade or so.’
What are your priorities for outcomes of collective action?
In our snapshot survey, we asked respondents to rank outcomes of collective action in order of priority. The three most important were: increased overall funding, highlighted problems within general practice, and increased patient safety.
These hoped-for outcomes of collective action are important to not just current GPs, but also the future workforce. A GP partner in Leamington Spa, Warwickshire, said: 'We hope it will result in a more realistic and better care outcome. We need to protect young GPs who can’t cope with two to three problems every 10 minutes with all the admin on top. Workload has increased 30% since Covid, and ARRS is little help - it is not value for money. General practice is triage and you need GPs to do this best. Due to successive governments' sustained under-resourcing, family doctors are being forced to take action to protect general practice for the general public.'
Why aren't you engaging in collective action?
Our survey also asked practices not engaging in collective action for their reasoning. The overwhelming response was a worry about patient harm, with many also not convinced that collective action will achieve anything. Joint CEO of Wessex LMC, Dr Laura Edwards, states that while the LMC is supporting those who wish to ‘rally their troops’ in collective action, they are ‘equally supporting those who are conscientious objectors - this is a marathon, and not a sprint.’
Is everyone in your practice in agreement about collective action?
The ballot for collective action was only open to GP partners to vote in, meaning that salaried and locum GPs did not have an official say. We asked respondents whether or not their practice staff were in agreement with collective action, and 68% said ‘yes.’
Some respondents mentioned that the time of the year has meant that it has been difficult to gather a full practice opinion on collective action. Dr David Coleman, a GP in Doncaster, says: ‘The decision was announced in the middle of summer holidays. All the partners won’t be in the same room until September to discuss things. The timing was really poor.’
Patient harm
Understandably, many GPs’ first concern when hearing the phrase ‘collective action’ was to worry about the impact on their patients. GPC chair Dr Katie Bramall-Stainer repeatedly ensured doctors and public alike that patients would not ‘come to harm’ as a result of these actions. However, in the run-up to collective action, NHS leaders voiced concern that A&E and other secondary services would suffer a catastrophic impact as a result of GP action. Even though the current phase of collective action involves no contractual breaches, GPs often go above and beyond their contract to provide care for their patients. Therefore, measures such as capping appointments, or serving notice on any voluntary services currently undertaken that plug local commissioning gaps could feasibly put patients at risk - even though GPs are fulfilling their contracts.
What effect do you think collective action will have on patient harm in the short term?
Short term is defined as the time collective action is taking place, and before any more concessions from government. Around 57% of respondents believe that collective action will have little effect on patient harm in the short term, but that number decreases almost by half to 29% when looking at the long term. In terms of any increase to patient harm: a quarter of GPs believe that there will be an increase (some or great) in harm to patients in the short term, but that figure drops to 19% in the long term. In the same vein, 46% of respondents believe that collective action will decrease patient harm (to some or great extent) in the long term.
What effect do you think collective action will have on patient harm in the long term?
In response to the ongoing collective action, a Department of Health and Social Care spokesperson said: 'This government is committed to shifting the focus of healthcare out of hospitals and into the community, to fix the front door to the NHS. We have already accepted the independent pay review body recommendation of a 6% uplift in GP pay and committed to hiring an extra 1,000 GPs into the NHS by cutting red tape, through an £82 million boost to the Additional Roles Reimbursement Scheme.
'Collective action will only punish patients. NHS England has preparations in place to ensure patient safety is protected and patients should still come forward for care as usual.'
If the BMA decides to escalate action to breach contractual obligations, would you be willing to take part?
Half of our survey respondents have said they would be willing to take part in escalated action to breach contractual obligations, if the BMA decided to do so. The GPC has maintained that this is the ‘first phase’ of collective action for GPs. An escalation to a second phase can be avoided if the Government agrees to make ‘contractual improvements’ in 2024/25 and restore GP funding to 2018/19 levels.
Phase two action could involve contractual breaches, ‘action short of strike’ and ‘strike action’ - which may include salaried GPs, registrar GPs and/or other practice staff. One GP partner, who is also a PCN CD said: ‘We're planning to gradually escalate our actions until a satisfactory agreement is reached with DHSC/NHSE.’
Since the ballot closed, the Government has accepted confirmed it will increase global sum by a total of 7.4% for 2024/25 in order to fund GP and practice staff pay rises worth 6%, and committed to hiring 1,000 GPs as part of ARRS. However, these measures have not quelled collective action so far, nor answered all concerns.
Pulse's survey on collective action
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