In the midst of what has become a highly confrontational year for the health service as different staff groups have clashed with the government, leading to strike action, the next battleground might just be in general practice.

After months of inharmonious negotiations between the BMA and NHS England, the latest update to the GP contract has been imposed on the profession for the second year running.

The BMA is set to have “serious discussions” with its members about what to do next, suggesting that it may issue a ballot to see if there’s support for industrial action.

The new contract covering 2023-24 has not gone down well in the medical profession, with the BMA saying that it “does absolutely nothing to improve what is fast becoming an irreparable situation for practices and their patients up and down the country”.

One of the union’s concerns is that it feels the contract is ignoring calls for any extra support to help practices meet the rising costs of keeping practices open.

“Despite warnings from GPC England, the contract also introduces more bureaucracy and arbitrary targets that only set practices up to fail and take GPs away from direct patient care,” said Dr Kieran Sharrock, the acting chair of the General Practitioners Committee (GPC), England.

Of course, practice managers are only too aware that there may be trouble on the horizon, especially considering the already impactful strikes undertaken by nurses and paramedics earlier this year.

Sympathy

Managers appear to be sympathetic to the doctors’ aims. As Robyn Clark, a director of the Institute of General Practice Management (IGPM), says: “I think the things that the BMA is fighting for are things that are all-important to us as managers. The main thing we need is investment.”

Another practice manager, who wishes to remain anonymous, states: “I think the doctors’ demands are entirely reasonable with one caveat. There’s been lack of investment in what we’re trying to do and we’re under a lot of pressure, and we’ve seen demand dramatically increase on top of the stresses of the Covid years. Everybody’s talking about packing it in…

“The caveat is that, yes, the core contract is being eroded, but I see much more money coming back into general practice through the vehicle of the PCN.”

Are strikes practical?

Compared with hospital staff, going on strike would not be at all straightforward for a GP, due to the employment status of general practitioners.

Robyn, who’s also a practice manager in Bristol, explains: ‘It’s tough because when you strike, you strike against your employer, but when you’re in a practice, the practice is your employer, so how do you marry that up? Who would be balloted – salaried GPs or GP partners?

“If you strike, you don’t get paid for that day, but if you’re the partner, do they stop our funding for that day? How are they going to calculate what a day’s work in general practice costs in order to dock it from us?

“Some people have recommended instead of full-out industrial action that we revert to contract, put in what the BMA deems is a safe staffing level and safe number of appointments, refuse to see anything over that, refuse all non-contractual work, stop all enhanced services and work to rule.”

Asked what her GPs would do if there was to be industrial action, she replied: “With younger GPs coming in and just finishing their training, they’re more aware of their rights and are ready to stand up for themselves. However, I think most GPs would be uncomfortable with the idea of refusing to see patients, but they’re wondering what else is left to do.”

The anonymous manager is sceptical that a strike will happen, claiming: “I think it’s possible that GPs will vote to strike, but whether they’ll actually do it when it comes to it is another matter.

“There’s no way they’re going to say no to seeing patients. I can imagine some level of non-compliance or saving some unnecessary workload that the NHS might throw at us, but I really can’t see GPs stopping seeing patients.

“If the GPC go into negotiations while having a strike ballot in their back pocket, that adds weight to the negotiation, but I can’t see it working. If we strike for two days, all that will do is push that workload into the next three days and the next week. The workload won’t go away.”

Alasdair McEwan, a practice manager in Ipswich, agrees: “Strike action by GPs is an extreme possibility. If they did, though, it’s almost more ammunition for the brigade who claim GPs are ‘lazy’. Having said that, I think the mood amongst GPs is quite mutinous just now.

“If it were to happen, I think it would be something like a ‘work to rule’ or some sort of heavily choreographed restriction. It could be specifically targeted, and there’s lots we could do to make life a little bit difficult further down the line without inconveniencing patients too much, but I don’t think it would be anything as extreme as ‘we’re not seeing any patients today’.”

Patient access

Patient access is a sticking point in the new contract and it has provoked much anger from doctors as well as PMs. The contract insists that GP practices offer patients an ‘assessment of need’ on first contact, which means they’ll ‘no longer be able to request that patients contact the practice at a later time’.

Robyn says: “Practice managers recognise the difficulties patients are experiencing with access to appointments. However, in the majority of cases, the problem lies not with how the practice structures their appointment system, but in their inability to keep up with rising demand. This is more directly as a result of reduced staffing, higher turnover, pressures on estates and a backlog of problems caused by delays for treatment in other parts of the NHS.

“Telling patients to call back at another time is a last resort, but more frequently this is the only option they have.”

The message being given in the new stipulation may only help to fuel patients’ dissatisfaction, as Robyn explains: “What staff get hit with more is the media onslaught. You only have to look at some of the tabloid headlines to see the impact that the contract announcement has made. We’ll see patients saying ‘you can’t turn me away now and you’ve been told that I have to be seen on the day’. That’s how they’ll interpret it.”

Real threat?

The BMA seems determined to take some form of protest or action over the imposition of the contract, and there’s little doubt that the current economic climate in the UK is making several groups of employees angry enough to go out on strike.

Will this include GPs though? Only time will tell, but striking won’t be straightforward for them. Perhaps a sense of inevitability that the situation won’t improve significantly until after a general election may keep industrial action at bay.

Meanwhile, unhappiness in general practice deepens, and many doctors may decide to leave the profession, making practice managers’ lives even harder as they struggle to fill vacant posts.