1. A non-statutory ballot by the General Practitioners Committee of the British Medical Association (GPC England) ran between 17 June and 29 July 2024, for GP BMA members to vote on a potential collective action. The ballot was held in response to the proposed incoming changes to the GP contract, due later this year. On 1 August 2024, the BMA announced that 98.3% of members that voted were in favour of, and were willing to take part in collective action. GPC England has invited GP contractor/partner BMA members to take certain actions, noting these actions may be permanent changes in some circumstances.
2. GPC England has identified 10 actions, and GP contractor/partner BMA members will be able to choose which of these actions they want to take, depending on their patients, local contracts, and any feedback from their local medical committee (LMC).
3. GP practices, through their General Medical Services (GMS) and Personal Medical Services (PMS) contracts, are required to comply with the relevant Regulations (The National Health Service (General Medical Services Contracts) Regulations 2015 or National Health Service (Personal Medical Agreements) Regulations 2015 as applicable). This document sets out the proposed GPC England actions but also summarises certain contractual requirements (‘National Contractual Requirements’), explaining the key points in the National Contractual Requirements that will continue to apply to all GP practices throughout any period of collective action. NHS England is looking to help GP practices and integrated care boards (ICBs) to ensure they are clear about the National Contractual Requirements that must continue to be fulfilled.
4. In addition to the National Contractual Requirements, this document also sets out the requirements for trusts to improve the primary/secondary care interface. This work should also continue to be implemented throughout any period of collective action.
5. All parties will need to work together to ensure patient safety is maintained throughout any period of collective action.
Considerations for ICBs and GP practices
6. The 10 actions proposed by GPC England as part of the collective action are listed below:
- Limit daily patient contacts per clinician to the UEMO (European Union of GPs) recommended safe maximum of 25. Divert patients to local urgent care settings once daily maximum capacity has been reached. We strongly advise consultations are offered face-to-face. This is better for patients and clinicians.
- Stop engaging with the e-Referral Advice & Guidance pathway – unless it is a timely and clinically helpful process for you in your professional role.
- Stop supporting the system at the expense of your business and staff – serve notice on any voluntary services currently undertaken that plug local commissioning gaps.
- Stop rationing referrals, investigations, and admissions:
- refer, investigate or admit your patient for specialist care when it is clinically appropriate to do so
- refer via eRS for 2-week wait (2WW) appointments, but outside of that write a professional referral letter where this is preferable.
- Switch off GPConnect functionality to permit the entry of coding into the GP clinical record by third-party providers.
- Withdraw permission for data sharing agreements that exclusively use data for secondary purposes (that is, not direct care).
- Freeze sign-up to any new data sharing agreements or local system data sharing platforms.
- Switch off medicines optimisation software embedded by the local ICB for the purposes of system financial savings and/or rationing, rather than the clinical benefit of your patients.
- Practices should defer signing declarations of completion for “better digital telephony” and “simpler online requests” until further GPC England guidance.
- Defer signing off “better digital telephony”: do not agree yet to share your call volume data metrics with NHS England.
- Defer signing off “Simpler online requests”: do not agree yet to keep your online triage tools on throughout core practice opening hours, even when you have reached your maximum safe capacity.
- Defer making any decisions to accept local or national NHS England pilot programmes during the proposed period of action.
Limiting daily patient contacts per clinician
7. GP practices which decide to limit daily patient contacts per clinician will, on request by the Commissioner, need to provide assurance that patients who contact the GP practice will continue to be appropriately triaged. For completeness, the relevant requirements are set out in the National Health Service (General Medical Services Contracts) Regulations 2015, Schedule 3, Part 1, Paragraph 4 (in the box below) noting equivalent provisions are included in the National Health Service (Personal Medical Agreements) Regulations 2015, Schedule 2, Part 1, Paragraph 5, (as amended). In the following excerpt, “core hours” are 8am-6:30pm, Monday to Friday (excluding bank holidays).
4(1) The contractor must take steps to ensure that a patient who contacts the contractor —
a) by attendance at the contractor’s practice premises;
b) by telephone;
c) through the practice’s online consultation tool within the meaning given in regulation 71ZD(2); or
d) through a relevant electronic communication method within the meaning given in regulation 71ZE(3),
is provided with an appropriate response in accordance with the following sub-paragraphs.
4(2) The appropriate response is that the contractor must —
a) invite the patient for an appointment, either to attend the contractor’s practice premises or to participate in a telephone or video consultation, at a time which is appropriate and reasonable having regard to all the circumstances;
b) provide appropriate advice or care to the patient by another method;
c) invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves; or
d) communicate with the patient —
i. to request further information; or
ii. as to when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances.
4(3) The appropriate response must be provided—
a) if the contact under sub-paragraph (1) is made outside core hours, during the following core hours;
b) in any other case, during the day on which the core hours fall.
4(4) The appropriate response must take into account—
a) the needs of the patient, including the need to avoid jeopardising the patient’s health
b) where appropriate, the preferences of the patient; and
c) any benefits to the patient of providing for continuity of the health care professional involved in their care and treatment.
8. There are a range of ways by which GP practices meet this requirement, including implementing Modern General Practice Access (MGPA), which supports practices to safely and effectively triage all patients that contact the practice, on the same day. If a GP practice opted to implement a blanket incoming call diversion, preventing patients from contacting the GP practice at any point during core hours, the GP practice would not (except potentially in most exceptional and very time limited circumstances) be meeting these requirements.
9. The obligations contained in paragraph 4(4) (of the box above) mean that the needs and preferences of the patient must be taken into account when taking any of the actions included in paragraph 4(2). This includes inviting the patient for an appointment. It would not be in accordance with this process for a GP Practice to only offer face-to-face appointments. To be in accordance with the Regulations GP Practices should make a judgement on what type of appointment would be suitable based on the needs and preferences of each individual patient, rather than taking any blanket approach.
10. Regulation 71ZF of the GMS Regulations (with equivalent wording in 64F of the PMS Regulations) also obliges GP Practices to offer and promote video consultations to its registered patients. GP Practices must therefore ensure that video consultations continue to be available to patients, and are offered where appropriate.
11. GP practices must ensure that, in the case of an emergency, essential services and minor surgery funded under Global Sum are available throughout core hours. These requirements are set out in the National Health Service (General Medical Services Contracts) Regulations 2015, Part 5, Regulation 20(2) (in the box below) noting equivalent provisions are included in the National Health (PMS Medical Service Agreements) Regulations 2015, Schedule 2, Part 1, Paragraph 1.
(2) A contract must also —
b) contain a term which requires the contractor to provide —
i. essential services, and
ii. minor surgery funded under the global sum,
at such times, within core hours, as are appropriate to meet the reasonable needs of patients; and
c) contain a term which requires the contractor to have in place arrangements for its patients to access essential services and minor surgery funded under the global sum throughout the core hours in case of emergency.
12. On request, GP practices will need to be able to assure their commissioners that the GP practice is continuing to meet the reasonable needs of the patients of the GP practice. The commissioner can request evidence of how the GP practice is meeting this requirement.
Stop rationing referrals, investigations, and admissions – Refer via eRS for 2-week wait (2WW) appointments, but outside of that write a professional referral letter where this is preferable.
13. Since 2018 it has been a requirement that GP Practices must use the NHS e-Referral Service (e-RS) where it is referring any of its registered patients to a first consultant-led out-patient appointment for medical services (GMS Regulations Schedule 3 Paragraph 11A/PMS Regulations Schedule 2 Paragraph 16A). There are only two exceptions where a GP Practice is permitted not to use e-RS. The first of these is where e-RS is not yet in place for that practice. The second is where there are technical or practical difficulties which prevent the use of e-RS, and the Commissioner has been notified of this issue.
14. Where there is a deliberate referral of a registered patient to a first consultant-led out-patient appointment for medical services via any method other than e-RS (and neither of the exemptions set out above apply), this action would not have been taken in accordance with the GMS/PMS Regulations.
15. Under SC 6.8 of the NHS Standard Contract, Trusts are not required to accept referrals by GP Practices to Consultant-led acute outpatient services that are not made through the e-RS, and each Trust must implement a process for communicating any non-acceptance to the patient’s GP without delay so that the GP can take appropriate action. Commissioners are obliged to ensure that GPs are made aware of this process.
16. There are no national regulatory or contractual requirements regarding the form that a referral must take, provided it is made via the e-RS. As long as the necessary information has been properly provided by the GP Practice in relation to the e-RS referral then a Trust will be obliged to accept it in accordance with SC 6.13.1 of the NHS Standard Contract.
Switch off medicines optimisation software embedded by the local ICB for the purposes of system financial savings and/or rationing, rather than the clinical benefit of your patients
17. In addition to the requirements set out in the GMS/PMS contracts, those GP practices which deliver services through a primary care network (PCN) model must also ensure they operate in accordance with the requirements set out in the Network Contract DES (directed enhanced service) specification. This includes certain medicines optimisation requirements for PCNs. The relevant requirement is set out below:
8.1.9 (a) “detail the measures a PCN will take to improve medicines optimisation and implement those measures, including ensuring medicines management and use of structured medication reviews for high-risk cohorts, as specified in the guidance. This should include medicines optimisation strategies for reducing polypharmacy, minimising risk of prescribing harm, reducing over-prescribing and managing the risk of dependency on prescription drugs”.
18. Any PCN whose member practices are taking action to switch off medicines optimisation software will need to ensure that the PCN is still meeting its Network Contract DES contractual obligations and, as with other contractual requirements, the commissioner may request assurance from the PCN of continued compliance.
Withdraw permission for data sharing agreements which exclusively use data for secondary purposes (that is, not direct care)
Freeze sign-up to any new data sharing agreements or local system data sharing platforms
19. There are a number of national contractual requirements for GP practices to share data, both with NHS England and, operating as a delegate for NHS England, ICBs. Commissioners and GP practices should ensure they are aware of these requirements as these must continue to be fulfilled during any period of collective action.
20. GP practices must continue to participate in the following data collections:
- The National Diabetes Audit (GMS Regulation 74B, PMS Regulation 67B)
- Information relating to indicators no longer in the Quality and Outcomes Framework (GMS Regulation 74C, PMS Regulation 67C)
- Information relating to alcohol related risk reduction and dementia diagnosis and treatment (GMS Regulation 74D, PMS Regulation 67D)
- NHS England Workforce Collections (GMS Regulation 74E, PMS Regulation 67E)
- Data relating to appointments in general practice (GMS Regulation 74H, PMS Regulation 67H)
- Data concerning use of online consultation tools and video consultations (GMS Regulation 74I, PMS Regulation 67I)
- Additionally, GP Practices must continue to submit the following:
- Information relating to overseas visitors to NHS England (GMS Regulation 74F, PMS Regulation 67F)
- Information to the MHRA (Medicines and Healthcare products Regulatory Agency) Central Alerting System on request (GMS Regulation 74G, PMS Regulation 67G)
- Information to NHS England as part of the annual return and review (GMS Regulation 77, PMS Regulation 70)
21. Additionally, GP Practices must continue to submit the following:
- Information relating to overseas visitors to NHS England (GMS Regulation 74F, PMS Regulation 67F)
- Information to the MHRA (Medicines and Healthcare products Regulatory Agency) Central Alerting System on request (GMS Regulation 74G, PMS Regulation 67G)
- Information to NHS England as part of the annual return and review (GMS Regulation 77, PMS Regulation 70)
22. GP practices must provide any information reasonably required by NHS England for the purposes of, or in connection with, its contract along with any other information which is reasonably required in connection with NHS England’s functions (GMS Regulation 74, PMS Regulation 67).
23. Commissioners and GP practices should also note that from the 1 October 2024, GP practices will be required to provide digital telephony data to NHS England (this will be set out in GMS Regulations Schedule 3, Part 1, Paragraph 2, PMS Regulations, Schedule 2, paragraph 3). Although this requirement is not yet in force, NHS England is taking the opportunity to alert commissioners and GP practices to this incoming requirement as this may be a relevant factor in any decision making by GP practices during any period of collective action.
Practices should defer signing declarations of completion for “better digital telephony” and “simpler online requests” until further GPC England guidance
24. In respect of Capacity and Access Support Payments, commissioners and GP practices should have regard to the requirements of paragraphs 10.4A.1 – 5 of the Specification to the Primary Care Network Contract Directed Enhanced Service (PCN DES) and paragraph 11.3 of the Part B Guidance – Non-clinical to the Network Contract DES. NHS England would alert GP practices to the requirement for digital telephone data to be routinely used to support capacity/demand service planning and quality improvement discussions which forms part of the assessment criteria for improvements when assessments are made in relation to the Local Capacity and Access Improvement Payment.
25. Table 1 (assessment criteria) on page 52 of the part B guidance states for all improvement areas: “All PCN practices to have following components in place and these continue to remain in place”.
- Better digital telephony
- Digital telephony solution implemented, including callback functionality; and each practice has agreed to comply with the data provision notice (DPN) so that data can be provided by the supplier to NHS England.
- Digital telephony data is routinely used to support capacity/demand service planning and quality improvement discussions.
- Simpler online requests
- Online consultation (OC) is available for patients to make administrative and clinical requests at least during core hours.
- Practices have agreed to the relevant DPN so that data can be provided by the supplier to NHS England as part of the ‘submissions via online consultation systems in general practice’ publication.
- Faster care navigation, assessment, and response
- Consistent approach to care navigation and triage so there is parity between online, face-to-face and telephone access, including collection of structured information for walk-in and telephone requests.
- Approach includes asking patients their preference to wait for a preferred clinician if appropriate, for continuity.
26. If GP practices are participating in collective action, and they have any concerns that they may not be fulfilling their contractual obligations, including those provisions described in this guidance, we would encourage them to seek their own advice on their individual circumstances, to satisfy themselves that they continue to meet their obligations under the contract.
Continuing to improve the primary care/secondary care interface – actions for NHS trusts
27. The outcome of the non-statutory ballot supported collective action, but in any case and in the normal course of business, it is in the interest of GP practices, patients and hospitals for the ongoing primary care/secondary care interface improvement work to continue.
28. The joint NHS England and Department of Health and Social Care (DHSC) Delivery plan for recovering access to primary care, published May 2023, is a key commitment that sets out a series of measures to enable transformation and support general practice to address the challenges it faces and improve patient access.
29. To improve interface working, NHS England commissioned the Academy of Medical Royal Colleges (AoMRC) to undertake a rapid and clinically-led review. Their report – General Practice and Secondary Care: Working better together – was published alongside the delivery plan.
30. Specifically, the plans asks ICB chief medical officers to establish local mechanisms that allow both general practice and consultant-led teams to raise local issues, to jointly prioritise working with LMCs, and to tackle the high-priority issues. These issues include those in the AoMRC report, more particularly:
- onward referrals
- complete care (fit notes and discharge letters)
- call and recall
- clear points of contact
31. The obligations for trusts to improve the primary/secondary care interface are also set out in the NHS Standard Contract. Service Conditions (SCs) 3.4-15 require an annual joint assessment to take place no later than 30 September in each contract year between each commissioner and provider. This should assess the “effectiveness of their arrangements for managing the interface between the services and local primary medical services, including the provider’s compliance with SC8.2-5, SC11.5-7, SC11.9-10, SC11.12 and SC12.2”. Subsequent action plans should, in discussion with LMCs, be put in place to address any deficiencies and progress should be monitored.
32. NHS England continues to drive engagement on this important issue at a national level by establishing a community of practice, which includes participation in our new FutureNHS page (log in required). The purpose here is to encourage the building of networks and relationships, enabling practical sharing of issues along with solutions.
33. Finally, the NHS 24/25 priorities and operational planning guidance requires every trust to have a designated lead for the primary/secondary care interface and asks that ICB boards regularly review progress.
Publication reference: PRN01459