GPs in England have gone on strike for the first time in 60 years. The 10 actions they can choose from could bring the NHS to a standstill. Their vote, announced last week, reached boiling point, with 98.3% voting for industrial action against the impossibly inadequate 1.9% budget increase awarded to practices by the previous government. It is a warning sign for a service on the brink of collapse, they say. The shortage of GPs is so alarming that the Health Secretary, Wes Streeting, last week announced plans to more than 1,000 GPs this year as an emergency ‘first step’ measure after arriving at the office and bluntly stating that ‘the NHS is broken’.
Some media outlets strongly criticized the GPs. The Mail found one who earned £700,000 – who likely ran many clinics – but the average GP wage in 2021/22 was £118,100. Why they have become scapegoats for the right is hard to fathom given that, by any measure, they are among the most pressured and most productive staff in the NHS, with an increase of 6.4 million patients registered with a GP in England since 2015.
In any case, the strikes are not primarily about pay, but about funding to keep a service running that provides up to 90% of all careand whose share of the NHS budget has fallen to the lowest level in eight years with only 8.4%. Although the previous government promised 6,000 additional GPs in 2019, the number has actually fallen while their workload has increased by 20%with much more difficult cases. England spends less and has fewer doctors and general practitioners per capita than almost any other EU15 country.
The Conservative vote collapsed partly because of public satisfaction with the NHS dropping to the lowest point everwith only 29%. Yet 71% of people in England still value their own GP experience highly. Hospitals under great pressure have cut their outpatient clinics and are sending most patients needing treatment for diabetes, mental health and other specialist care back to their GPs. This is euphemistically called ‘shared care’, but it is now almost entirely done by GPs. Sick patients on long waiting lists for surgery are filling up extra GP appointments, while people who are living longer need more GPs to care for older people with multimorbidities. ‘My wonderful profession is collapsing,’ says Prof Dame Clare Gerada, a GP from south London and recently president of the Royal College of GPs, almost despairingly. ‘We get 30p per patient per day, less than the cost of an apple.’ She is a patron of Doctors in Distress, a charity that aims to reduce doctor suicide, so she sees their suffering. She and Dr Phil Hammond are on the outskirts of Edinburghto gather support to save the NHS.
The threat of follow-the-rules labour action includes the eye-catching warning that GPs could cut the number of patients they see to just 25 a day. Forty a day is normal, usually. The BMA lists 10 ‘actions’ that GPs could take, such as stopping sharing data with third parties, no longer seeking advice and guidance before referring patients to specialists, and other minor spanners in the works for the NHS system.
The most important demand is a new contract that reflects what GPs do now. Every recent review shows that the current Carr-Hill formula for allocating funding, based on the 1991 census, does not take deprivation into account. The complex set of hundreds of indices that determine how GPs are remunerated does not help poorer areas achieve the high vaccination and cessation rates that are easily achieved in rich places, says Gerada. The most radical demand from GPs is a major shift in NHS funding from hospitals to GP practices and their community services.
Dr. Katie Bramall-Stainerchair of the BMA GPs committee and chief negotiator, tells me that GPs are “leaving en masse” as innate NHS forces suck money into hospitals, leaving less and less for the services that best keep people out of them. The power of consultants and the political fear of growing hospital waiting lists override all the evidence that prevention, public health and community treatment are the best hope of improving the nation’s health. She is demanding a 1% annual shift in funding from hospital to community, so that primary care gets 5% more in five years.
She’s absolutely right. But here’s the strange thing about it all. That’s exactly what Labour thinks, and has always said. It’s in the manifest and in every speech Streeting makes. So why is the BMA taking action after just a month against a new government that is on their side? I sense a certain embarrassment about this, as GPs I have spoken to are not sure it makes sense. Nor does it sound like many will take action that patients would notice. The anger and despair at not being able to provide a good enough service, and the pressures of hours and administration, are genuine enough. This all started with a referendum of GPs in March, long before the election was called.
Streeting’s team tells me that their approach to GPs is: “Take a breather. The people across the table have changed in everything we believe. We completely understand why GPs wanted to kick the previous government up the backside. We are not being belligerent, we are completely on board.” Streeting and his officials have met Bramall-Stainer on several occasions. Frankly, it doesn’t sound like she’s keen to fight. They all seem to be sitting down to discuss a major shift from hospital to community, which Streeting has already sent advisers, including Prof Lord Ara Darzi, to report on next month.
As promised during the election campaign, Streeting quickly settled with the junior doctors’ leaders. But recent waves of NHS strikes since 2022 by nurses, hospital doctors, physiotherapists, paramedics and others have led to the postponement of almost 1.5 million appointments, procedures and operations, costing the NHS an estimated £3 billion – a long-held act of bravado by the previous government when staff had taken real pay cuts. A full-blown strike by GPs would be even more catastrophic. But as GPs know only too well, that would risk causing far more public unrest, outrage and patient suffering, which is why these opening salvos have so far amounted to little more than an SOS distress signal.
In a curious replay, the last time GPs took action was at the advent of Harold Wilson’s government in 1964, when they resigned en masse, undated, as a threat. It was settled. Negotiating a new contract that reflects the complexity of the work that GPs have been saddled with by hospitals – and the extra services they are willing to provide to move care into the community – looks set to be difficult and protracted. At least both sides are starting on the same side of the table, but don’t underestimate the desperation of GPs.