General practice: the seeds of discontent

Posted 23 Jul 2024

The results of the BMA’s ballot of GPs are now in, and GPs have voted overwhelmingly in favour of taking collective action, such as limiting the number of patients they see each day. But how did we come to this?

An overwhelming 99.2% of GPs and GP registrars voted to reject the 2024/25 GP General Medical Services contract (19,009 votes were cast, 18,854 rejected it),¹ but NHS England (NHSE) and the Department of Health and Social Care (DHSC) have imposed it anyway, and it came into effect on 1 April 2024.²

As a result of this imposition, the BMA – the doctors’ trade union – conducted a ballot on whether or not GPs should take 'Collective Action', planned to take place during the second half of 2024.¹ This article will describe the background to the discontent and discuss some of the reasons behind it.

HOW DOES FUNDING WORK?

First, let us understand how funding works in general practice. GP partners are independent contractors who enter into a contract with NHSE to deliver General Medical Services (GMS) or Personal Medical Services (PMS). They are not NHS employees. They receive funding from NHS England for each patient on their list, currently £107.57 per patient for 2024/25.³ They may also get additional sources of income such as QOF payments, Locally Commissioned Services, or deprivation top ups. The GP partners/contractors are responsible for costs and overheads, which are wide ranging and can include everything and anything – staff salaries, business rates, electricity, gas, indemnity, insurance, cleaners, parking, tax and so on. What is left in the end is profit, split by the partners as income. Due to inflation, the margins are becoming ever tighter, as the cost of running the business continue to rise.

Funding has not risen at the same rate as inflation. Inflation is eroding the real term value of core practice funding. For example, Consumer Price Index (CPI) inflation was 21.2% from April 2019 to April 2023.4 However, the 2019-2024 contract investment only grew by 12.5%.⁴In real terms, this is a funding cut. This spells disaster for many GP practices who are struggling to pay costs and overheads. Their profitability is eroding to the point that some partners are earning equivalent to or less than a salaried GP. This may push many GP partners to leave. Practices may also struggle to stay financially viable and maybe forced to close or merge.

NHSE does offer uplifts to help with rises in costs and inflation. The uplift for general practice in the 2024/25 contract is £215m. This is broken down into £24m (1.68%) for inflation (based on GDP deflator forecast), and £35m (0.38%) for population growth. There is a 2% pay increase for GP contractors (£64m), and 2% for salaried GPs and other practice staff (£91m).⁴The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) may recommend a further uplift (but there is no guarantee that the Government will accept the DDRB’s recommendations). However, this is simply not enough: practices are struggling to pay overheads associated with previous year’s inflations. The BMA is pressing for a 8.7% uplift in 2024/25 to address the CPI inflation of 21.2 % from 2019 to 2023.⁴

It might be argued that there has been additional funding for Primary Care Networks (PCNs).⁵However, PCN funding is separate from the funding for the GP practices, and it cannot be spent on hiring more GPs or paying for overheads in GP surgeries.

GP MORALE

Secondly, it is important to acknowledge that it isn’t just funding that is driving GPs to collective action. Let us understand the morale and feeling among GPs at the moment.

GPs are struggling with workload. A typical day would be a morning clinic of 15 patients (10 to 15 minutes per consultation), followed by a possible home visit, and an afternoon clinic of 15 patients. Throughout the day, GPs have to complete time consuming administration which can take hours – this can include a mountain of prescriptions, letters, laboratory reports. They also have to support and supervise those in Additional Roles Reimbursement Scheme (ARRS) roles (e.g., pharmacists, paramedics, physician associates). On top of this, they often have to respond to emergencies and urgent queries. A typical day includes 2 sessions (each session is 4 hours 10 minutes, so should amount to 8 hours 20 minutes of work).

However, often GPs are working 10-12 hours per day. This equates to unpaid overtime. Many GPs are burning out, and the number of permanent fully qualified GPs has decreased by 1,924 (6.7%) from September 2015 to March 2023.5

GP partners have to do all the clinical work as described above, but in addition, they have to run a business. Countless hours each week are devoted to running the practice, and participating in endless meetings – partnership meetings, project meetings, supervision of trainees, PCN meetings, local medical committee (LMC) meetings. The list is long, and often this additional work is done outside of core working hours. This is why partners offer added value. They often work for no additional pay to keep the business going. They have a vested interest in keeping the business running smoothly. It is important to remember that they have professional liability for the business and also unlimited financial liability. So they could lose their personal assets, including their home, if the business fails. As discussed above, on top of the pressures of being a GP partner, business profitability is eroding due to inflation, and more and more GP partners are choosing to vote with their feet and leave partnership. Between March 2016 and March 2023, the number of GP partners has decreased by 4,923, a decrease of 22.9 %.⁵With declining GP partner numbers, GP surgeries will be forced to hand back contracts and close down. Since April 2013, 1,600 practices have merged or closed.⁶

In addition to burnout and dwindling partnership profits, demand from patients is becoming unsustainable. It seems there will never be enough appointments to satisfy demand. We are offering more appointments than ever, but still it does not seem to be enough.⁵Complaints from patients seem to be increasing. The media rhetoric – of greedy and lazy GPs – has created a hostile environment to work in, and patients have become less trusting and respectful of GPs. Talking to peers, it is now embarrassing to declare you are a GP in a social gathering. On top of this, we are asked to do more with less funding, and you can now see why general practice is in crisis.

LOOKING TO THE FUTURE

We now have a new Labour Government. Will they do anything different to the previous Conservative Government? Wes Streeting, the new Health Secretary, has said in the past ‘I’m minded to phase out the whole system of GP partners altogether and to look at salaried GPs working in modern practices alongside a range of other professionals’,7 …only to backtrack later saying he now recognises ‘the value GP partners provide’.⁸Will he be a friend or foe to general practice? With collective action looming, only time will tell.

As Dr Katie Bramall-Stainer, chair of the BMA’s GP committee (GPC England) said ‘When I qualified as a GP in 2008, general practice was "the jewel in the crown of the NHS". Fast forward to 2024, we are witnessing a ‘constructive dismissal’ of general practice across England…in 20 years, I’ve never known GPs to be so frustrated, angry and upset’.⁹

Hence collective action is being proposed for the second half of 2024. There are nine actions from which GP practices could pick and choose, including limiting daily patient contacts to 25 per clinician, stopping voluntary services, stopping the rationing of referrals/admissions/investigations, switching off medications optimisation software (for financial savings). The BMA has reassured GP practices that the nine actions will not breach their contract. The BMA expects the collective action to be a ‘marathon, not a sprint’. ‘This is instead, an opportunity for a collective professional reset, to draw a line in the sand and say “no more”.’1

In conclusion, my dog costs me over £600 per year to insure, whereas GPs receive just £107.57 per patient. As the BMA says, this is less than a cost of an annual TV licence or an apple a day.¹⁰The Integrated Care Board spend on primary care is 8.4% in 2023/24.¹⁰ The BMA is calling for a 2025 Family Doctor Charter which commits to a floor of 15% of NHS budget allocated to primary medical services.¹⁰This is to ensure that adequate funding is provided to primary care so that it can continue to be the backbone of the NHS. As Professor Kamila Hawthorne, Chair of Royal College of General Practitioners aptly said, ‘When general practice is allowed to crumble, the whole of the NHS fails’.¹⁰

So my message to Wes Streeting is this: ‘Please do not let general practice crumble….we are too important to the NHS’.

General practice: the seeds of discontent

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