BMA recommends dangerous GP contract changes – Paramedics to be substituted for GPs

March in Tower Hamlets against the closure of local GP surgeries in the borough

THE British Medical Association’s (BMA) GP England (GPCE) committee has voted to accept a dangerous package of changes to the GP contract for 2020-21.

On 23rd December 2019, the new draft specifications for the English national GP contract for the year 2020/21 were published by NHS England (NHSE), the market-orientated commissioning board of the NHS. This opened a three week consultation running to the 15th January 2020.
The response to this consultation by area GP leaders, was fast and furious and very hostile to its proposals.
For example, on 9.1.20 the Berkshire Buckinghamshire and Oxfordshire LMC (Local Medical Committee) said it could not endorse the draft proposals.
They wrote: ‘These specifications carry an extremely high workload which would be impossible to deliver based on the available workforce within the health system.
‘These specifications offer no benefit to practices and are completely unrealistic.
‘We do not recommend practices to renew the Network Contract DES in 2020.’
They claimed that to provide the five extra services demanded, would cause practices to face a deficit of £100,000 per year.
The demand for GPs to do a fortnightly ward round in care homes for the elderly, they said was impossible on top of their full time work in their surgeries.
The mandatory Structured Medication Review (SMR) service to reassess the multiple drug prescriptions of complex patients, was another task which LMCs, say they don’t have the staff for. Three other new services; ‘Anticipatory care,’ and ‘personalised comprehensive care’, and ‘Supporting early cancer diagnosis’ were also required.
All the new targets (called metrics) would be closely monitored electronically on a ‘Network Dashboard’.
By 13.1.20 the Clinical Directors (CDs) of the 18 Primary Care Networks (PCNs) in Dorset, unanimously rejected the draft Network Contract DES specifications for 2020/21 and resigned their posts saying their tasks were impossible.
In Guildford and Waverley, all the PCNs advised their practices not to sign the Network Contract DES for 2020/21, unless it is significantly altered, due to the ‘overwhelming clinical and financial burdens’ … ‘which will dramatically destabilise primary care.’
There were similar comments from Birmingham and Lincolnshire and other parts of the country. In London, a campaign group called ‘GP Survival’ raised over a thousand signatures against the draft specifications in a couple of days, because of ‘an impossible amount of additional unfunded work’.
GP Dr Nick Mann, commented that NHSE started out on this journey by saying that if GPs can’t make PCNs work, they would end up working as salaried staff for ‘other providers’. He called the new PCNs the basis for ‘the global health model of managed care’.
The background to this groundswell of opposition, is that in January 2019, shockingly, the English BMA’s GP’s committee (GPC) voted to accept a new national GP contract without the standard ballot of BMA GP members.
From January to June 2019, GPs running GP practices, were coerced by their union, the BMA’s English General Practice Committee (GPC), and the Clinical Commissioning Groups ( CCGs) to join up to an extra contract – a Network Contract DES, on top of their normal core GP contract under which they provide primary medical care to NHS patients.
This would involve signing a Network Contract DES and a legal so-called ‘integration’ Network Agreement to join into one organisation with other medical providers, public and private, such as community providers, hospitals, and social care. GP practices must thus form the basis for wider Primary Care Networks.
This creation of Primary Care Networks through signing the Network Contract DES was said to be the cornerstone of the new GP contract.
The ‘NHS Long Term Plan’ proclaimed that the new PCNs are the building blocks of Integrated Care systems, covering 1-2 million people.
At the heart of the new PCNs is the conception that 26,000 new non-doctor staff should be recruited into PCNs and become part of a ‘joint workforce’ to be run by the GP practices in the PCNs and the other community and medical providers, over time, with which they would be ‘integrated’.
These new staff are to be formed into ‘multidisciplinary teams’, and be employed to do tasks which were previously the work of GPs!
The intention of the new GP contract is to substitute paramedics for doctors in general practice, as part of a gigantic re-structuring of GP care in England, and inaugurate ‘scale’ multispecialty community providers, eventually linking up with hospitals, to form integrated care systems and integrated care providers modelled on the US healthcare system.
In the US, healthcare for profit is provided by Health Maintenance Organisations and Accountable Care Organisations, dominated by the big private health insurance corporations.
The process of driving GP practices into PCNs was completed in just six months in 2019. Most GPs did not realise it was voluntary and had no idea what it fully entailed.
The BMA told them that the signing of a second network contract would help them save their core independent contractor model of NHS general practice. There would be more money for both contracts, plus insurance indemnity.
Given that general practice in England is in a colossal funding and workforce crisis, due to ten years of funding cuts and ‘reforms’, many GPs did not have time to read the complicated and unreadable reports – ‘The NHS Long Term Plan’ 7.1.19 and ‘Investment and Evolution: A five year framework for GP contract reform to implement the NHS Long Term Plan’ 31.1.19. The latter was a collaborative joint publication by NHSE and the BMA.
GPs were told by their union and the CCGs, that the new Network Contract DES would provide them with more money and more non-doctor staff, to supposedly alleviate their financial and workforce problems. So they went along with signing up to the second Network Contract DES and became part of a PCN.
In this way the GP partners running 7,000 GP practices were herded into 1,259 Primary Care Networks, covering 30 to 50,000-plus NHS registered patients each in 2019.
This was a colossal secret top-down reconfiguration of the NHS and a huge pro-privatision blow to the NHS.
But, the extra services required by the Network Contract DES in 2019/20 were only the thin end of the wedge of the plans for more services to be provided by PCNs over the next five years.
In 2019 this started softly with requirements for extended hours of access, the sharing of patients’ medical data with other practices in the network, big data collection schemes and moves to recruit new non-doctor network staff, (initially pharmacists and social prescribing receptionists.)
As a result of this, hostile responses to the draft specs for 2020/21 ( see above), the GPC committee – which re-met on 16th January 2020 – voted by 80% to reject the draft Network Contract DES specifications for 2020/21.
Not only that, GPC agreed to condemn these specifications, and demanded the holding of an emergency LMC conference to consider the outcome of the 2020/21 GP contract negotiations and what action the profession should take.
No date for this emergency LMC conference has been set. It was to take place AFTER the GPC had agreed a new contract for the year with NHSE!
On 6th February, GPC agreed a new set of specifications for the Network Contract DES 2020/21 to take effect from April 2020.
On 8th February the BMA organised a special PCN conference in Birmingham to explain the contents of the new contract.
Dr Vautrey, the chairman of GPC, recommended the new agreement to the BMA membership.
A considerable increase in funding for the networks is involved.
A few of these new proposals follow:

  • NHSE has agreed to 100% NHSE reimbursement of the salaries of the new non-doctor staff, as opposed to 70%;
  • an extra 26,000 of these extra non-doctor staff will be employed by 2023/24;
  • There will be further ‘new roles’ for these staff, so altogether there will be social prescribing link workers, clinical pharmacists, pharmacist technicians, first contact physiotherapists, clinical paramedics, physicians associates, care co-ordinators, health coaches, dieticians, podiatrists, occupational therapists, and mental health professionals over time;
  • GPs themselves will not have to perform the fortnightly care home visits, this can be done by the PCN ‘multidisciplinary team’. PCNs will receive £120 per care home bed, to pay for this service;
  • The structured medical reviews will only be provided in line with the number of clinical pharmacists to do it;
  • There is funding for various schemes to try and attract more GPs into general practice.

The ‘Update to the GP contract agreement 2020/21- 2023/24 6.2.20’, jointly produced by the BMA and NHSE, is 86 pages long.
It remains to be seen whether an emergency LMC conference will be arranged and if so, whether motions opposing the whole project to create PCNs and ICSs will be allowed on the agenda.
Those attending and speaking at the LMC conference are representatives.
This confernce, if it takes place, is no substitute for a members’ ballot of BMA GP members.
The outrage of the GPC agreeing to a contract without a ballot of the BMA GP membership in January 2019 is now compounded by the outrage of GPC agreeing an update to the national GP contract in England again, on 6th February, without a membership ballot.
It now appears that the BMA is jointly producing with NHSE annual agreements to GP contract change, which the members are told to accept.
The BMA is more and more overtly behaving like a company union.
It is certainly not explaining to its members the colossal privatisation implications of this five year framework of GP contract change.