Friday, February 01, 2008

Stroppy GPs

For some time now, the government have been piling the pressure onto "greedy" GPs. Having renegotiated their contracts and utterly fucked up the whole process—managing to achieve a triple whammy of screwing the GPs, the patients and the state's coffers simultaneously—NuLabour have been angling to renegotiate yet again.

Now, as you will know, I am not a cheerleader for the medical profession in any way whatsoever. However, I am a cheerleader for anyone who aims to make life really fucking difficult for this government. Thus, I have no hesitation in republishing this email received by the momentarily-out-of-hiatus Politicalog.
I received the following email yesterday and have decided to post it pretty much “as is”. The only thing I have removed is the name of the author who is a GP and on the GPC. The contents pretty much speak for themselves...

So, what does it say? Well, firstly, I assume that GPs have been offered two different contract options, referred to here as Option A and Option B. The rest, as Allan says, speaks for itself; I particularly like the line, "We are not negotiating with honourable people."
Dear All,

We currently appear to be being steered towards accepting imposition A simply on the grounds that in the short term we will take less of a financial hit. I think this is probably dangerous and that we will regret it next year if we do not stand our ground now. It will be your decision. There has been criticism that the GPC is not prepared to give a steer. They are in a difficult position and are still trying to formulate questions that will make it clear that if you accept imposition A then it is only under protest as being the least unpalatable of two unacceptable options. We are not negotiating with honourable people. I certainly hope myself that if you go for option A when you are asked to vote then no one at all in Gloucestershire or Avon will then do any extended hours surgeries whatsoever; regardless of how much you might be bribed to do so.

For what its worth my personal view on the way forward is: -
  • Reject both A & B. Stay cool and then point out that the stand-off between us is another “faut pas” by Gordon Brown in person, caused by his insistence on the over-riding of his own negotiators. He is getting a reputation in the media for someone who cannot delgate any power. I think he is vulnerable and will not want an epitaph as being the man who destroyed the NHS. Unless we reject both A&B we are not in a state of “dispute” and cannot legally hold a ballot on any form of industrial action.

  • Publicise widely that the Government has lied, interfered with the pension settlement, and has betrayed doctors who signed up in good faith to what they believed to be legally binding contracts, and that the NHS can no longer therefore trust Gordon Brown. Seek a General Election if feasible by whatever means available to us legally. Posters seeking that might help. Gordon Brown has no personal mandate as Prime Minister from the general population.

  • Stress publicly the underlying privatisation agenda, with loss of the traditional family doctor as being our major concern.Stress Government intention to use nurses, pharmacists, emergency care practitioners, and overseas doctors from Eastern Europe as cheap GPs.

  • Take every possible opportunity to educate patients in our daily dealings with them. It is very easy to drop in a relevant critical comment or two about the Government in general conversation. It is after all only informing them of the truth. If we all do this then hopefully opinion polls will rapidly show an impact based upon our disillusionment with the Labour Party. Our strength lies not necessarily in our patients’ support, but in our ability to influence them on matters political, such as the threat to the continuation of the NHS, via our frequent one to one contacts.

  • Continue to publicise the enormous achievments and benefits of the new GMS/PMS contracts to patients, but don’t expect too much from patients as the media campaign against us has been too effective. They do indeed view us as fat cats now.

  • Illustrate to patients that already practices are planning staffing cuts that will make it more difficult for them to access an already understaffed and underfunded primary care service, including access to both doctors and also to practice nurses. (Don’t forget our nurses now often have as big a following as do the GPs - they spend longer with each patient and that can be interpreted as being a more personal service by the patient. Patients don’t understand the delegated responsibility.)

  • End practice based phlebotomy and anticoagulant control. It might cause patient protest, but we can simply point out the scale of cuts and that we can no longer afford it. That should soon cause a public outcry.

  • Expose the cuts to practice-based primary care teams, with the associated widespread downgrading of senior clinical nurses and cuts to health visiting and midwifery, leaving but a few only as managers for groups of practices, simply to save money. Point out how this undermines team spirit, and has resulted in delegation of important clinical work to very much more junior nurses who often do not have the necessary skills etc.

  • Expose the gross inadequacies of the emergency OOH services compared to those that GPs ran before PCTs took over. Also expose cuts to the ambulance services.

  • Insist that the employers element of superannuation is handed back to PCTs immediately and is not in future recorded as part of our income whether intentionally or otherwise.

  • Try very hard to use BMA lawyers to establish that the contract cannot be broken unilaterally as there is no “natonal emergency”. If necessary insist on a judicial review as delaying tactic if nothing else, regardless of what the BMA lawyers think about likely outcome, or whether the BMA quibbles about paying for one. (I have serious doubts about the BMA’s willingness to support our campaign financially. It has spent too much on gutting BMA House!)

  • Insist on the declared support of the wider BMA, which I don’t feel we have at present. If not forthcoming consider establishing a break-away organisation outside of the BMA, which I will personally be prepared to become involved with , I daresay along with others on the GPC.

  • Seek a European judgement based on the current “Working Time Directive” etc. Lobby Euro MPs. If necessary get BMA lawyers to seek changes to European law along the lines of maximum time that pilots/lorry drivers are allowed to work without a minimum break.

  • Seek support of Medical Defence Organisations to resist the enforcement, by financial threat or otherwise, of doctors having to work alone doing booked surgeries with just a prescription pad at antisocial hours, when they will obviously be at risk.

  • Ballot on industrial action to comply with Trade Union law, and don’t leave this too late.

  • Insist as far as possible that all GPs act in unison throughout the UK. Peer pressure will be vital for success. Get LMCs to prebook a series of large-scale meetings now.

  • Make it clear to Government that refusal to negotiate fairly will mean an immediate embargo on all further IT developments including National Spine, electronic prescribing, GP to GP etc.

  • No statistical or survey information of any kind to be fed to PCOs in future.

  • Withdrawal from all PBC and C&B developments by ALL GPs, with refusal to engage in commissioning of any sort until satisfactory resolution.

  • Refusal to develop QUOF in any way.

  • Refusal to engage further with “Access”.

  • Doctors currently doing any extended hours will be asked to stop doing them for the time being as part of the national campaign of unity.

  • There will be an end to any attempts to reduce referrals to secondary care which most of us have cooperated with to date. Any referrals sent back to practices by the inevitable referral management centres that will result, will be returned with a note to the PCT asking them to confrm acceptance of legal liability, and those patients affected will be given a letter to take to their MP.

  • An end to any further generic prescribing.

  • An end to 28 day prescribing, and a return to presciption for quantities of drugs dictated by clinical considerations only.

  • Refusal to agree to any “drug switch” campaigns, whatever short-term savings there may be for PCTs.

  • Seek to establish our right to treat any patient privately outside contracted hours, as per consultants. If rejected insist that consultants should have that right to practice private medicine withdrawn if they hold an NHS post.

  • Refusal to train new GPs until satisfactory contractual negotiations are re-established.

  • Encourage GPs to withdraw from OOH arrangements until satisfactory in hours contractual arrangements are restored.

  • Insist that attached staff being accommodated in GP owned or leased surgeries are rehoused.

  • Collect undated resignations.

  • Point out to all managers just how vulnerable their jobs will be if we all resign.

  • Ask for a detailed public analysis of the value of SHAs by the National Audit Office, with the intention that they are scrapped.

  • Set up immediately a subcommittee that will assist the process of resignation if we are forced to go that far, will negotiate for a “Mediplan” type insurance etc., and will produce detailed guidance notes for GPs.

  • Publicise that it is Gordon Brown personally who is responsible for threatening the NHS by starting yet another unnecessary war.

  • Publicise that we have always been prepared to negotiate on detail of contractual arrangements and on improving patient care in line with updated evidece bases, given the necessary resources and professional respect, but that the outline of the 2003 contract is written in stone, and that general practice cannot continue without inflationary uplifts plus significant extra funding in addition in order to cope with the ageing population, developments in medical science, and new treatments.

  • Publish comparative cost tables for drug costs, primary care costs, and overall health costs for all European countries.

  • Insist that comparability is restored as a factor that must be taken into account by the DDRB in assessing GP pay.

  • Call a Special Conference of LMCs, or convert the Annual Conference into a Special Conference solely for decision on the agreed way forward.

  • Consider as an option seeking mass PCTMS salaried contracts as “consultants in primary care”. I was at a dinner yesterday with a PCTMS GP . He is a senior doctor, but he is paid £90,000 all found. (The contract includes Crown indemnity, maternity and paternity leave, sick leave, NHS pension, all staff and premises provided etc). He is taxed by PAYE so does not have the disadvantage of payment of Schedule 4 tax in advance. I think many could find the advantages of such salaried contracts backed up by PROPER GPC negotiation (instead of the half hearted support so far given) attractive compared with what we now face as supposedly “independent” contractors.

  • Resign en-masse from GMS/PMS contracts as last resort on a pre-determined date following the Special Conference.

We live in interesting times, no?

Still, that reminds me: I should probably register with a GP at some point...


C said...

Hi Devil,

Interesting indeed but the question I want answered is why is the government negotiating this at all? Surely it is up to hospitals, practices, etc to decide how much and who they pay. Any contract involving all GP's will have problems, compromises and of course the unintended consequences that our current political masters are so good at.

Tomrat247 said...

Interesting point in the text:

"Set up immediately a subcommittee that will assist the process of resignation if we are forced to go that far, will negotiate for a “Mediplan” type insurance etc., and will produce detailed guidance notes for GPs."

A quick google search of the phrase "mediplan" reveals an austrian based social insurance scheme that actually appears quite fair.

Are we that far from a european social insurance scheme after all? At this rate Labour will be forced out by a landslide, the Tory's having no choice but to kow tow the line and annex NIC's into general income tax, reducing it to emergency care & long term health provisions, leaving the GP's to "do a dentist".

This could really have been sorted had the coal-face of the civil service been able to adopt locallised measures for sorting out pay.

The Great Simpleton said...

I have the same sympathies for the GP's as I have for the police - if the Govt can't be trusted to honour a contract then we are well and trully fucked.

As you say we are in for intersting times. This is obviously self serving but there are some very interesting points:

"I think he [Gordon Brown] is vulnerable and will not want an epitaph as being the man who destroyed the NHS"

But it might do us all a favour so that we can start again and set up something that is designed to deliver health care and not keep one of the world's largest workforce occupied.

"An end to 28 day prescribing, and a return to presciption for quantities of drugs dictated by clinical considerations only"

I know its a bit niaive but I would like to think my doctor was prescribing the amount of drugs I need based on clinical need and not Govt diktat.

Anonymous said...

Yes, the loyalties of the BMA are suspect . Many of the negotiators , not all , are Labour fellow travellers and have worked for and with that party in the past eg in the 1977 election and since .

Incredibly , the author still refers to "the NHS" and appears to have no comprehension that there are now four of them with different bosses , different finding, different aims , different government departments to deal with and different sets of politicians to face . It apears he is referring to the English NHS only although he doesn't know it . Such naivety , plays straight into the hands of the British government which still runs the English NHS .

In spite of this naivety, widespread in the profession ,a lot of what he says is perceptive particularly when referring to patient attitudes and government manipulation of them .
One of the most marked points is the now generally unchallenged acceptance that there is a world of possibility outside "the NHS" eg with an insurance based alternative and that this could happen quite quickly . Such a suggestion would have produced an outcry within the profession a few years ago . Nowadays it merely results in resigned,even interested, acceptance .
Many medics are belatedly becoming like the dentists . They have clung to the idea a universal NHS much longer but now see it not working for much longer ( the Labour government is imposing new contracts with private organisations for GP services almost daily - yes , the Labour government !)

The dentists would now never go back now and I can see this happening to the medics before too long .

James Barlow said...

The references to Avon might imply the PCT in question is the Bristol NHS PCT.

I've found the out-of-hours press office number, so I'll give them a bell tomorrow (sat) morning. Or if you're keen you can do it now.

Henry North London said...

the BMA is spineless

They back down at the first sign of trouble

Would you like me to pass it on to the Guardian and see if I can get a response?

Gordon is breaking Eu Contract Law

So we can prosecute him

Dr John Crippen said...

Excellent post.
Where do most GPs stand on this? I don't know for certain. There is a lot of vitriol and anger in the privacy of DNUK (why some journo hasn't been in there, lifted large parts of it, and given it some publicity is beyond me – some people think I am “off the wall” : you should see what some of my colleagues say in their private forums) but, however much huffing and puffing there may be, I doubt GPs will strike.
But we are very demoralised. The government set up the hoops and targets and the bonus payments. We jumped through the former, hit the latter, earned the bonus payments, and then got slagged off by Hewitt for taking the money. The work we did was not of great value in terms of health care but we did not design it. The government did. But make no mistake, had we NOT done the work we would have been slagged off for being lazy.
For the government and most of the media, doctors in general and GPs in particular are the coconut shy for people to vent their anger at the failing NHS. And, believe me, it is failing.

Every article on medicine in the papers or on the BBC is prefaced with a remark along the lines of "GPs don't know much about....", filled in with a few lines about how idle we are, and finished with a few snotty remarks about earning over £100K for bugger all work.
We did not design the current health care model. We hate it even more than you. Most of us are decent people, and most of us work very hard. We want to do what we trained for - see people who are ill, and help them with their illness. That is not trendy any more. The government wants health police officers, and someone to pander to pillocks who think it is there god-given right to summon a “free” (aka tax-payer funded) doctor to their house at midnight to look at their sore thumb.Doctors are not very good at doing surveys, monitoring people’s lives, and interfering with personal freedom.
I do not give a fuck if you smoke and drink. I am not interested in phoning you up to ask you how many cigarettes a day you smoke (and, yes, I do get incentive payments for doing that). I think that the state SHOULD do its best to educate people about healthy living but it should be on an advisory basis only. No compulsion. If, however, a patient comes to me for help with smoking and drinking then I am happy to provide it. And yes, I will, with his consent, check his cholesterol and sugar and BP and PSA etc etc as indicated.
You are a lover of language. Please don't use the word "contract" in this context. A "contract" is an agreement freely made between two parties negotiating at arm’s length. What the government is proposing is the imposition of working practices.
But, however bad it is, I will not strike. Couldn’t do it. I will continue to provide healthcare for my patients as best I can. I will not phone them up and nag them. They will have to come to see me. I already work from 7.30 am until 6.30 pm (8.30 pm on one night) and I will not work more than that. I will happily do some surgeries on Sat or Sunday, but they will be instead of one on Monday or Tuesday. Take your pick. Most patients I see are under school age, pregnant or retired. They prefer to come during the week. The sensible people at work come down at 7.15 am and are seen.
Having worked a full day, I will not get up at 2.30 in the morning, as I did for 20 years, go to see a shift worker with a painful ingrown toenail and then work another full day. I cannot do it. And there is no amount of money the government could realistically pay me to make me do it.
So, I shan't strike. I shall work on. But, if it becomes intolerable (and it is close) I shall quietly resign. As will many thousands of others. I suspect that is what the government wants. But don't worry, they have trained up legions of fast tracked (see The Army) health care quacktitioners who will take over.


John said...

By the way, DK, I know no one will be noticing today, the second day of the second month, but you are not fooling me. What's with this American date format?

You haven't fallen under the influence of that nice Mr Bush, have you?


Dr John Crippen

Dr Grumble said...

The journos are beginning to grasp what some of this means.

Anonymous said...

the author betrays a basic misunderstanding of the situation which is fatal to his credibility as a GPC member.

When he says 'reject both A and B" he is talking arrant nonsense.

The only offer on the table is "A". "B" is the Government response to a rejection of "A"; (and if "A" is accepted will be Governments offer next year with a worse gun to the head.)

Devil's Kitchen said...


Re: date format. I am afraid that Blogger does not seem to provide the date format that I want (date and time on every post) in an English version. Irritating, but what can one do...?


Dr Rant said...

You should come and register at my surgery.

You think you're intemperate?

You should meet my team of reception staff!

Devil's Kitchen said...

I'm not actually registered with a GP at present. Are you based in South London, O Rant Team...? ;-)


Dr Blue said...

The Rantinghouse Surgery is in Rantingshire. Which a bit like Llareggub is not a very specific address, although it is out of the smoke, and distinctly provincial.

Oh, and we tend not to care what the what the neighbours say.

Henry North London said...

Be a little more specific and then I can find a nice GP for you Devil

Devil's Kitchen said...


I live at the top of Brixton Hill, so I guess I am covered by Brixton and Streatham.


Henry North London said...

ok have put the word out that a fiend needs a GP ( friendly jest there)

Will let you know