The BMA have begun to ballot GPs in response to the Tower Hamlets motion passed at LMC conference in May which said:

“That conference believes that the GP Forward View is failing to deliver the resources necessary to sustain general practice and demands that GPC ballot GPs as to whether they would be prepared to collectively close their lists in response to this crisis.”

It is beyond doubt that General Practice is in meltdown. Despite the best efforts of GPC Executive all we have been offered is a totally inadequate GP Forward View and a couple of other sweeteners such as reimbursement of CQC fees.

STPs will finally push us over the edge as patient care is moved out of hospitals into an already oversaturated community to “save” £22 billion in England.

Collectively closing our lists to manage our workload would benefit the safety of our registered patients and send a message to the Government that we cannot continue to work under the current level of pressure.

Many forms of action to reduce our workload, such as refusing to cooperate with CQC inspections, would risk practices being served with breach notices. List closure however is allowed under GMS and PMS contracts to give practices: “a degree of workload control…. in situations of workforce or recruitment difficulties that affect a practice’s ability to provide to an acceptable and safe standard.” Given that 84% of us said last year that our workload undermines our ability to provide safe patient care, most of us can surely argue that we can temporarily close legitimately on this basis.

Practices in areas of high turnover may be concerned that list closure will result in sharp drops in income as patient numbers fall. This could be mitigated by choosing a maximum list size which enables safe patient care, closing when the list exceeds this number and opening again when it drops below. The requirement that practices opt out of additional and enhanced services if they close their patient list, is no longer in the regulations. There will thus be no impact on the services practices are currently commissioned to provide. Collective list closure would mean lack of access for some but General Practice will collapse and there will not be access for anyone if we do nothing. Patients will support us if we explain that we want to provide safe, comprehensive General Practice to everyone, but that in the current climate this is not possible. We do not contemplate this action lightly, but the Government have not listened to years of warnings and General Practice is now on the point of collapse. We struggle to provide a safe service due to our workload and this is not good for patients. Many already understand the pressures that the health service is under, 250,000 marched in defence of the NHS earlier this year.

Patients can be engaged by asking them to sign petitions in our waiting rooms or to write to their MP.

The Government could easily avert this crisis. They could:

  1. Accept the GPCs Urgent Prescription for General Practice in full
  1. Take responsibility for indemnity as they do with hospital doctors.
  1. Allow patients to refer themselves directly for services such as antenatal care, weight management programmes and physiotherapy to remove this needless administrative burden from General Practice.
  1. Get rid of the hoops that we are forced to jump through for tiny pots of money, such as those in the GP Forward View, and put these sums into our baselines to allow us to plan our services.
  1. Assure rights of residency for non UK born doctors and nurses so that these valuable NHS staff stay.
  1. Stop outsourcing to profit driven companies like Capita whose appalling service causes daily chaos.
  1. Resource the NHS adequately. We are the fifth richest country in the world and can easily afford the NHS which remains the most cost effective health care system in the developed world. In 2015 the UK spent 7.3% of GDP on the NHS. This is lower than comparable European countries and is set to decease to 6.6% by 2020. The UK has fewer hospital beds per head at 2.8/1000 than the OECD overage of 3.3 and has fewer doctors and nurses per head than comparable developed nations.
  1. Abolish the NHS market, which fragments the health service and costs billions to administer.
  1. Repeal The Health and Social Care Act, with its myriad of committees and procurement panels which take us away from patient facing care.
  1. Abandon the STP project.

The key to success is in the word “collective”. We must all take part. Together we are strong. Of course there are risks and none of us will undertake this lightly but we cannot continue to work under these pressures. It is not safe for patients. If Government won’t listen we must make them listen.

Q: Why are we balloting for willingness to take action?

A: It is beyond doubt that General Practice is in meltdown. STPs threaten to finally push us over the edge as they demand £22 billion in “efficiency savings” Young doctors are not choosing General Practice as a career and many older GPs are retiring early. To add insult to injury the public sector pay cap has meant that doctors have effectively taken a 22% pay cut in the last decade. Despite the best efforts of GPC Executive all we have been offered is a totally inadequate GP Forward View and a couple of other sweeteners such as reimbursement of CQC fees.

Q: Why are GPC proposing list closure?

A: General Practice is governed by contract. Refusing to comply with many clauses in the contract, such as refusal to cooperate with CQC, would risk a breach notice. List closure however, if carried out on the grounds of patient safety, is allowed under the contract.

“A practice can decide not to register new patients, provided it has ‘reasonable and non-discriminatory grounds for doing so’, (such as protecting the quality of patient services.) In such cases, the regulations allow practice to refuse to register new patients (Schedule 6, Part 2, paragraph 17).”

Q: What should I say to patients?

A: Be honest. Tell them we regret taking this action and do not do it lightly, but that the Government have not listened to years of warnings about the strain on General Practice and that now it is on the point of collapse. We have to do something to stop it breaking down altogether. We struggle to provide a safe service due to our workload and that this is not good for patients. Ask patients to support you, put a petition in the waiting room and ask them to write to their MP. Our patients are the strongest weapon we have in fighting for general practice. Tell them what you are doing and why.

Q: My practice has a high turnover, if we close our list we will rapidly lose income.

A: For practices like yours, consider deciding a minimum list size to sustain the service, then temporarily close your list until patient numbers had dropped below this. You could then re-open until your safe limit was reached, closing again and so on. Remember the aim is to highlight the dangerous working conditions we all face and the impact this has on patient care. You can still achieve this.

Q: What about the patients who are not registered with a GP?

A: GPs will remain able to see patients as temporary residents in emergency circumstances. We regret that this action will mean a delay in registering fully with a GP, but failure to act will lead to the collapse of General Practice which would mean a lack of access for all. As a profession we do not do this lightly, but the risk to our patients is greater if we do nothing. NHS England will still be able to allocate patients to closed lists, as is the case currently in many areas where all practices have closed lists. If this list closure happens nationwide however it causes a significant increase in workload for NHSE, as well as public embarrassment to the government.

Q: I understand the need to take action but I am nervous.

A: Of course. We are a caring profession who are reluctant to do anything to hurt or upset our patients. Having considered many options, we genuinely believe this is the best choice to cause maximum disruption for Government, but minimal harm to patients. The risk of continuing to provide care at this unsafe workload outweighs the risk of carrying out this action.

Q: Why are we balloting for “collective” list closure?

A: Because together we are much stronger and can have a much bigger impact. If we stand united across the profession, supporting each other we can make rapid gains. Uniting GPs across the country means we can deliver a stronger message and hopefully achieve our aims quickly.

Q: What do you want the Government to do?

A: There are many things that Government could do. These are some suggestions:

  1. Enact BMA policy and fund the NHS to the level of comparable countries and at the same time increase the proportion of NHS funding which is allocated to General Practice to at least 15%.  In 2015 the UK spent 7.3% of GDP on the NHS. This is lower than most other European countries and is set to decease to 6.6% by 2020. The UK has fewer hospital beds per head at 2.8/1000 than the OECD overage of 3.3 and has fewer doctors and nurses per head than comparable developed nations. Despite this the NHS is regularly found to be the most cost effective health care system in the developed world.
  2. Take responsibility for GP indemnity in the same way that they do for hospital doctors.
  3. Allow patients to directly refer themselves for services such as antenatal, terminations of pregnancy, podiatry, physiotherapy, weight management programmes etc, to remove needless administrative burden from general practice.
  4. Remove all of the hoops that we have to jump through to for example obtain the tiny pots of money in the GP Forward View. Funding must be made directly available for all practices.
  5. Deal with the incompetence of companies such as Capita and NHS Property Services whose failures cause such time wasting in surgeries.
  6. Sort out NHS Property Services so that they stop wasting practices time with repeated premises surveys and sending unjustifiable service charge bills.
  7.  

    Attract doctors and nurses into General Practice, both young doctors and those who have left. Increasing doctors and nurses will help decrease the workload which 84% of us have said undermines our ability to provide safe patient care and enable us to provide a safe service for patients.

  8. Confirm the residency status of all non British born doctors and nurses immediately so that they remain here making their vital contribution to our health service.
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