In June the BMA opened a ballot for GP partners to vote on “Collective Action” (not strike action) because it was clear that the GP contact was underfunded and GP practices continues to be overstretched, being asked to do more, with less. This ballot asked GP partners if they were willing to take measures to highlight the challenges in funding and workload that we are all experiencing, such as withdraw from some non-contracted services, cap number of appointments or stop using some referral forms. 

The ballot result was massively in favour of Collection Action and the process implementing this started in early August. Many of the actions practices will take, will not impact patients as they are purely administrative changes. However, some practices will take action that will change how patients can seek healthcare from their GPs in the months ahead.

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Why am I and many others like me in support of Collection Action?

The most important thing for patients to understand is why GP practices are taking part in Collective Action. The most important thing for patients to understand is that you are at the heart of this. We are doing this for your benefit – to ensure your local practice has the capability to provide high quality patient care and to safeguard the future of one of the “front doors” of the NHS. GPs want to put patients first. We want to provide long term, continuity of care. I want to be proud of the job I am doing.

If we continue to work with poorly funded contracts, practices will have to reduce the services they offer, or sadly, close altogether. This is a scary prospect. From a selfish perspective, I want to enjoy my job as much as I used to, for it to be fulfilling and rewarding like it was 10 years ago. I don’t want to feel constantly frustrated that my patients are not getting the care they so desperately need, in the timeframe they need it.

It is important that everyone of us understands what Collective Action is, and how you might be impacted. We are doing this for you.

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The Collective

The definition of collective is “done by people acting as a group” but I cannot help thinking of the hive mind of the Borg (yes, I am a Trekkie)… Whichever way we think about the term, it highlights the need for togetherness, to harness the benefits of working as a team for one central aim.

What is the aim?

Simply, to save general practice and protect its future. General practice needs to thrive, not just survive this challenging time.

For the first time in my career, I have questioned whether being a GP is good for me. Is it a sustainable career that I can enjoy for another 30 years? No, not at the moment.

Why carry on?

Because for the first time in my career, I have seen GPs join as one profession. Not individual practices, networks or federations. As one team across the country, with the same goals and aims. I have heard a few people say, “the cardigans are off”, and they are right. We are drawing a line in the sand, putting ourselves out there and saying that the funding and support for general practice is not enough. We are a Collective.

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What do I mean by funding?

It is important to understand a little bit about the funding streams for general practice, and then it is easier to see why this kind of action is important – for patients now, and those in need of our care in the future.

A practice is funded in many different ways, here are a few of the funding streams:

• GMS global sum – this is the core pot on money, each practice signs a contract with the NHS to provide certain services. This is dependent on the number of patients a practice has and how deprived/rural the area is. GPs and nurses are paid from this global sum and it hasn’t matched inflation for the last 20 years. This which means we cannot afford to expand the workforce to address the increasing health needs of the nation.

• QOF – practices earn money based upon meeting targets for a number of specified long term conditions, immunisations and cervical screening rates to name a few.

• Enhanced services – these are optional services a practice can be paid to provide e.g. blood taking, ECGs, coil fitting, wound care and many more.

• Additional services – further optional services including minor surgery.

• Some practices take on private contracts e.g. providing medical services to schools or prisons.

The funny thing is, before I went to medical school – I used to think hospitals did specialist clinics, surgeries and had A&Es and GPs did everything else. I didn’t think there was a list of things that they were funded to provide and offer. GPs just mopped up all the things the hospital couldn’t or shouldn’t do. Or even worse, did the things that the hospital told them to do.

How wrong I was.

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Why does the funding matter to you?

The funding each practice receives pays for staff, medical equipment, utility bills, upkeep of the buildings, insurance…to name just a small list of what the outgoings are. Often I am told the solution to the crisis in GP access is to get more GPs or make the GPs already working, work harder or longer. The less money we have to pay staff or spend on equipment, the less we can provide high quality care to you and your loved ones.

What about PCNs and ARRS?

Five years ago the Primary Care Network contract came in with the a separate budget to pay for additional roles. Wonderful, more money to general practice to spend on staff. Millions more. But we couldn’t use it to bring in more GPs. We have some brilliant Allied Health professionals working at the practice because of this additional funding. The extra money it is ring fenced, we cannot use it to give an uplift in salaries to receptionists or pay for a repairs to a leaky roof.

Why not just get some more GPs instead?

Because many practices simply cannot afford to.

I know it is extremely difficult for many patients to access timely routine GP appointments with their practice. Asking GPs to work harder or work longer will just drive more GPs away from the job. Instead, we need to make the job rewarding, sustainable and ensure we have time to provide high quality care and continuity to our patients.

The collective needs a better proportion of the overall NHS funding pot going to general practice and each practice needs to be able to determine what to spend that money on – more staff (or the opportunity to offer pay rises which are much deserved), updating the GP building or providing more services. It feels like our hands are tied at the minute, costs are rising (heating bills, staffing costs, buildings insurance etc etc have all increased) but the funding has been pretty much static.

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What will Collective Action look like?

I have seen parts of the media call this “work to rule”. The BMA have suggested nine actions that a GP practice might take as part of this action and each practice can decide what to do. They might decide to do one or nine of the actions. The full list is here:

https://www.bma.org.uk/our-campaigns/gp-campaigns/contracts/gp-contract-202425-changes

Patients won’t notice some of them, as they are related to data sharing or usage of specific telephone systems. There are two actions that patients may feel the effect of:

Capping of appointments and stopping of doing unfunded work:

“Limit daily patient contacts per clinician to the UEMO recommended safe maximum of 25. Divert patients to local urgent care settings once daily maximum capacity has been reached. We strongly advise consultations are offered face-to-face. This is better for patients and clinicians”

Why is capping appointments better?

Do you want to be the 30th patient a doctor has seen that day or the 1st? Every 15 minutes my brain has to entirely shift topic. From miscarriage, dementia, slapped cheek to bowel cancer. I see an eclectic mix of people with multiple clinical symptoms and conditions. It is unsafe for clinicians and patients to just ask us to keep seeing more and more patients. This is very much an example of quality not quantity.

We do much more than simply see our booked patients everyday and we need to ensure time and resource is allocated to this important non-patient facing work.

You may see a quiet waiting room in the middle of the day, but me and my team are busy sendingreferrals, chasing up results, filing blood tests, communicating results to patients, supporting thereception team, debriefing GP trainees, attending meetings, issuing sick notes, writing medical reports, speaking to hospital doctors, district nurses and social workers… (maybe even fitting in a cuppa and a visit to the loo!!). 

I work a minimum of 10 hours on my clinical days. Capping the amount of direct clinical contact I have to the BMA safe working target, 6.25hours (25 x 15 minute appointments) means that I will be fresh and able to concentrate on all the other responsibilities. I have highlighted in other blog posts that the workload of a GP is difficult to quantify but ever increasing. Some weeks I work 60 hours and my poor husband and kids feel the brunt of that, it makes for a tired and irritable Abbie. It is important to me to find the balance of being a good mum to my two not-so-little kids, fit in some exercise and me-time, all while being a doctor, business owner and mentor to the next generation.

Does this mean some patients are turned away?

Yes, sadly it does. This is where pharmacies and NHS111 come in. Patients with minor illness can often seek advice or medication through these channels. Patients with longer term problems will likely get in touch another day and await an appointment as they value continuity. Patient care is already being seriously disrupted because of a lack of funding and that needs to change.

It is not sustainable in the long term. Do you want your GP to be tired and burnt out?

Cease providing some optional or unfunded services:

“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.”

Which services?

This one is more challenging to define as different areas get funded for various “enhanced services”. You may find your practice serves notice on a number of services such as post-operative wound care, blood taking, warfarin dosing, ring pessaries or specialist drug monitoring.

You will also see that many practices and GPs will start pushing back on the move of work from hospitals to GPs. They may not agree to prescribe medication, arrange blood tests or send a referral on a specialists behalf. We will be polite but firm when communicating this with a hospital clinician and we know this may impact the relationship we have with many trusts and departments – but this is vital – to really demonstrate the significant hospital related work that we have taken on without funding.

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I never thought I was a political animal, but the decline in general practice funding since I qualified 10 years ago has been significant and impacted both on the ability to provide sufficient appointments for patients and workload for all staff. The next generation of GPs need us to make a stand now, so we can safeguard the future of the profession. We try our best in the most challenging of times but this next 6 months will be key, we will hopefully see the best part of the NHS, general practice, flourish – to the benefit of patients and the rest of the NHS.

The power of the Collective is real.