GPs in England have embarked on industrial action for the first time in 60 years. The 10 actions they can choose from could bring the NHS to a grinding halt. Their ballot result, announced last week, blew the lid off a boiling pot as 98.3% voted for collective action against the impossibly inadequate budget increase of 1.9% awarded to practices by the previous government. This is a warning about a service on the point of collapse, they say. The lack of GPs is so alarming that the health secretary, Wes Streeting, last week announced plans to recruit more than 1,000 GPs this year as a “first step” emergency measure, after arriving in office and saying bluntly that “the NHS is broken”.
Some of the media slammed the GPs. The Mail found one earning £700,000 – who probably ran many clinics – but average GP pay in 2021/22 was £118,100. Why they have become the whipping boys of the right is hard to fathom when, by any measurement, they are among the most hard-pressed and the most productive staff in the NHS, with an increase of 6.4 million patients registered with a GP in England since 2015.
Anyway, the industrial action is not primarily about pay, but funding to keep a service running that provides up to 90% of all care, and whose share of the NHS budget has fallen to its lowest in eight years at only 8.4%. Though the last government promised 6,000 more GPs in 2019, the number has instead fallen while their workload has increased by 20%, with far more difficult cases. England spends less and has fewer doctors and GPs per head than almost any other EU15 country.
The Tory vote crashed partly due to public satisfaction with the NHS falling to its lowest ever, at just 29%. Yet 71% of people in England still rate their own GP experience highly. Hospitals under intense pressure have cut their outpatients departments, sending back to GPs most patients needing treatment for diabetes, mental health and other specialist care. That’s euphemistically called “shared care”, but it’s done almost entirely now by GPs. Sick patients suffering on long waiting lists for operations fill up extra GP appointments, while people living longer lives need more GPs to care for the old with multi-morbidities. “My beautiful profession is collapsing,” says Prof Dame Clare Gerada, a south London GP and recent president of the Royal College of GPs, sounding near to despair. “We get 30p per patient per day, less than the cost of an apple.” She is a patron of Doctors in Distress, a charity for reducing suicide among doctors, so she sees their anguish. She and Dr Phil Hammond are at the Edinburgh fringe, drumming up support for saving the NHS.
The threat of work-to-rule industrial action includes the eye-catching warning that GPs might cut the number of patients they see to only 25 a day. Forty a day is typical, usually. The BMA lists 10 “actions” GPs can choose to take, such as stopping data sharing with third parties, no longer seeking advice and guidance before referring patients to specialists, and other minor spanners to throw into the NHS system.
The key demand is a new contract that reflects what GPs do now. Every recent review shows that the present Carr-Hill formula for allocating funding, drawn up based on the 1991 census, fails to take account of deprivation. The complex set of hundreds of indices that dictates how GPs are reimbursed doesn’t support poorer areas to reach high vaccination and smoking cessation rates that are easily reached in wealthy places, says Gerada. GPs’ most radical demand is for a big shift of NHS funding out of hospitals into GP clinics and their community services.
Dr Katie Bramall-Stainer, chair of the BMA GPs committee and its chief negotiator, talks to me of GPs “leaving in droves” while innate NHS forces suck money into hospitals, leaving less and less for the services that best keep people out of them. The mighty power of consultants and the political fear of growing hospital waiting lists override all evidence that prevention, public health and community treatments are the best hope for improving the health of the nation. She is demanding a 1% funding shift every year from hospital to community, so that in five years, primary care will get 5% more.
She’s quite right. But here’s the oddity of all this. That is exactly what Labour thinks, and has always said. It’s there in the manifesto and in every speech Streeting makes. So why, after only a month, is the BMA taking action against a new government that’s on their side? I detect a certain sheepishness about this as GPs I have talked to are less than certain it makes sense. Nor does it sound as though many will take any action that patients would notice. The fury and despair about being unable to deliver a good enough service, and the strain of the hours and the admin, are genuine enough. This all began in March with a referendum among GPs long before the election was called.
Streeting’s team tells me their approach to GPs is: “Take a breather. The people on the other side of the table have changed in everything we believe. We completely understand why GPs wanted to give the last government a kicking. We’re not combative, we’re in complete agreement.” Streeting and his officials have met Bramall-Stainer several times. Frankly, she doesn’t sound to me as though she’s itching for a fight. They all sound likely to fetch up around a table promptly, talking about a major shift from hospital to community that Streeting has already sent out advisers, such as Prof Lord Ara Darzi, to report back on by next month.
As promised in the election campaign, Streeting settled with the junior doctors’ leaders rapidly. But recent waves of NHS strikes since 2022 among nurses, hospital doctors, physiotherapists, paramedics and others led to nearly 1.5m appointments, procedures and operations being postponed, costing the NHS an estimated £3bn – a stubborn act of grandstanding insanity by the last government when staff had suffered real pay cuts. An actual strike by GPs would be even more catastrophic. But as GPs well know, that would risk causing far greater public alarm, indignation and suffering to patients, which is why these opening salvoes are no more than an SOS distress signal, so far.
In a curious repetition, the last time GPs took action was on the arrival of Harold Wilson’s government in 1964, when they handed in mass resignations, undated, as a threat. It was settled. Negotiating a new contract that reflects the complexity of work GPs have been landed with by hospitals – and the extra services they want to provide to shift care into the community – looks set to be difficult and drawn out. At least both sides start out on the same side of the table, but don’t underestimate GPs’ desperation.
