Another funding storm is on the horizon with the recently announced rise in national practice contract funding for England.

For all the people working in general practice, a rise is a rise, but when it amounts to about 2% in the context of an overstretched service, in which some doctors working in other parts of the health service have been awarded double-digit pay rises, it’s easy to feel underwhelmed.

Even worse, this uplift to the GMS contract is in dispute and may take months to be agreed as the BMA’s members are considering taking industrial action involving doctors in primary care.

In this kind of climate, Practice Managers are understandably pondering what sort of steps they can take to keep their practices ticking over.

Funding impact

 The impact of the 2% uplift is going to be significant according to managers who are already having to swallow the financial hit of the recent 9.8% rise in the National Living Wage that came into effect on 1st April.

Helen Oakley, Business Manager at a practice in London, says: “I did an analysis. We pay more than the National Living Wage, but to keep that level above the minimum wage, we have put our pay up by 9.8% for the lowest-paid staff. And those who are paid slightly more also need a similar upgrade to keep the differentials. We’re spending around £5,000 more than our uplift – that’s what it’s going to cost us to make sure those who are on the lowest wages get the National Living Wage increase – the reception team, the admin team and the supervisors. There just isn’t enough money in the pot.”

The increase is going to be tough for many managers as Nicola Davies, Chair of the Institute for General Practice Management, points out: “You’ve got a group of people who are having what is effectively an over 9% pay rise on the National Living Wage. They all should be on more for the work they’re doing but we just haven’t got that funding.

“We’re a small practice, and that’s going to cost us in excess of £18,000. It’s not just the living wage; we have to factor in National Insurance contribution and the pension contribution. Then there’s a pay gap between those who are on the living wage and those members of your team who have worked with you for longer and have more experience. They’re paid more but that gap is now being squeezed.

“NHS England has suggested to the DDRB [Review Body for Doctors’ and Dentists’ Remuneration] that they offer no more than 2%, so the very people who are supposed to be helping and supporting us are telling the DDRB we’re not worth more than a 2% increase when we’re delivering more. How do you speak to your staff and say you’re worth more money, but I haven’t got it?

“Whatever we get as an uplift for staff, we’ll pass it on, but it’s still going to sting. I think it’s another slap for general practice that NHS England are sending a very clear message that despite the supportive words, they’re not supporting us.”

Ways to save money

As a result of the current financial squeeze, managers are having to come up with ways of saving money and some are bound to be unpopular. A recent discussion on the forum included several ideas, such as:

• Recruitment freezes and not replacing staff who leave
• Stopping the provision of services that practices aren’t funded to deliver
• Reducing holiday cover
• Pushing back on shared care agreements, particularly those with secondary care providers
• Increasing non-NHS charges
• Stopping some enhanced service contracts that are unprofitable
• Going back to an all, or almost all, telephone-only service

One Finance Manager said: “We’ll be pushing unpaid work back (i.e., shared care agreements), and enhanced service contracts that cost more to do than they pay will be cancelled.”

Helen says: “Every practice does stuff that they don’t get paid for because it’s in the best interests of the patients. An example is a menopause clinic. You don’t get paid to do the clinic. If you’ve got a GP who does a menopause clinic because they’ve got a speciality in it, you’re providing a gold standard service to those patients, but you’re not paid to give a gold standard service, you’re paid to give them a HRT prescription every three months with basic monitoring at appropriate intervals.”

Nicola adds: “If a member of staff resigns, potentially we’ll find practices who aren’t replacing that member of staff because they can’t afford to.”

Industrial action

Managers are taking the possibility of industrial action seriously, now that the BMA has written to NHS England to say that it’s formally “in dispute” with NHS England over the imposed GMS contract.

In February, the BMA’s GP Committee unanimously rejected the proposed changes and in March, a survey of more than 19,000 (almost 75%) of the BMA’s GP members got an overwhelming (99.2%) vote to reject the Department of Health and Social Care and NHS England’s imposed changes to the contract.

The BMA is now set to write to all ICBs in England to highlight the dispute and recommend that ICBs include potential GP action on their risk registers. A formal ballot of members on taking industrial action is expected, but no date has been set as yet.

In the meantime, Practice Managers are becoming increasingly resigned to industrial action taking place, possibly later in the year when winter pressures are starting to bite and any action is likely to have a bigger impact.

There has been talk of beginning with stopping all the unpaid work carried out in practices, before escalating to patient services that are least likely to hurt patients.

Ultimately, industrial action could develop into operating a more telephone-based service, which some managers feel could persuade the Government to improve its offer on the funding uplift.

Nicola says: “A strike could happen in November and that’s the worst time, but you have to strike at the worst time to make an impact. We’re going to be running flu and Covid clinics then and we’ll have high numbers of patients coming to see us.

“If I’ve got doctors going on strike, what plan can I put in place? I put out a call to our ICB to say we need to start thinking about this because this may well happen.

“If it does happen, regardless of when it is, NHS 111 and our emergency departments will be rammed. We’ve got some small hubs and minor injuries units which will also be rammed, but who are you going to get to staff those organisations if doctors have gone on strike?”

Helen adds: “The only industrial action I can think of is saying no to things that aren’t in the contract and which aren’t paid for. The trouble is, that then affects the quality of patient care.”

Who knew that managing a practice would require such high levels of juggling skills?