Background to the GP contract dispute
The referendum: 99.2% of 19,000 participating GP and GP registrar members rejected the contract changes
Following March’s unequivocal referendum result, where 99.2% of BMA GP and GP registrar members returned a resounding vote AGAINST the 2024/25 GMS contract changes, we went into dispute with NHS England.
The indicative ballot: 98.3% of participating members voted ‘yes’ for collective action
For the indicative ballot on collective actions of GP contractor/partner* members subsequently held in July, where seven in ten eligible members voted, an overwhelming 98.3% of participating members voted ‘yes’ and indicated their willingness to take action to save general practice. This was a means of gathering momentum ahead of organised collective action, which commenced from 1 August.
* The responsibility to deliver the GMS / PMS (Personal Medical Services) contract is held by the GP contractor / partner(s) of the practice. They are not NHS employees, but independent GPs who contract with the NHS. Unlike other NHS employees in other branches of practice, such as junior doctors and consultants, GP contractors / partners are not subject to TULCRA legislation, which is why an indicative ballot was held.
Action by GPs
Collective action is not strike action. Services will not be withdrawn in this initial phase of the campaign, and contracts will not be breached. However, the impact on NHS England and ICB (integrated care board) budgets will be felt keenly. England general practice currently receives 5.5p in every NHS pound, and, from October 2024, a GMS ‘global sum’ payment per weighted patient of £112.50 per annum.
Despite the 2024/25 6% DDRB-related national contract funding uplift announced by the new Government in August, CPI erosion to the GMS contract since 2018/19 is still £366 million – 3.6%. The consistent underfunding of general practice, following on from over a decade of successive Conservative governments, explains why, between 2013 to 2023, we lost around 20% of independent GP practices in England (Source: British Journal of General Practice).
GPC England wrote to Integrated Care Boards in April to request that systems add GP action to their risk registers to prepare to mitigate any such potential impact. Government, NHS England and the DHSC (Department of Health and Social Care) had known this would be the consequence of a third consecutive contract imposition for over a year.
The DDRB-related 6% uplift announced in August is welcome, as is the emergency inclusion of newly qualified GPs in the ARRS (additional roles reimbursement scheme), but these are both respectively only:
- getting us part of the way there to restoring national GP contract funding back to real-terms levels in 2018/19 and
- a short-term plug whilst we buy time to find a longer term employment solution.
We can only see a stop to further practice closures and an end to GP unemployment if we get round the negotiating table asap.
Practices facing shortfalls
The Government has committed to honouring the 2024/25 DDRB (Doctors’ and Dentists’ Review Body) recommendation of a of 6% uplift, after NHS England and the DHSC only provided an overall 1.9% national GP contract funding uplift in the interim in April 2024 – a real-terms cut in funding. GPCE could not have stressed more, or evidenced better, how precarious practice finances are at the moment, and as things stand, we remain greatly concerned that some GP contractors / partners will have to hand back contracts and close their practice before the new Government can intervene.
The Swingometer below shows that despite the DDRB-related 6% uplift in national core GP contract funding, practices will still be facing a real-terms shortfall in core funding compared with 2018/19. Funding hasn’t just stood still for the past five and a half years or so; it has reduced in value in terms of what it can pay for on behalf of patients.
Department of Health and Social Care / NHS England contract changes imposition
GPCE received notice from DHSC and NHSE of the 2024/25 contract changes at the end of February 2024. These had not altered despite three more weeks of discussions following GPCE’s rejection at its meeting on 1 February. Summary details are set out below:
(excluding the PCN directed enhanced service)
There will be an overall increase in investment of £215m in 2024/25. This assumes:
2% pay growth for contractor GPs (£64m), salaried GPs and other practice staff (£91m):A further uplift may be made following the Government’s response to the Doctors and Dentists Pay Review Body (DDRB) for 2024/25.
- 1.68% inflation (£24m), in line with the Government’s November 2023 GDP deflator forecast for 2024/25.
- 0.38% (£35m) ONS population growth.
- This means the contract baseline funding will increase from £9.2 billion to £9.4 billion in 2024/25. This is around 5% of the overall expected NHSE budget (£186.7 billion) for 2024/25 for core/essential general practice services.
- The Global Sum payment per patient will be £107.57 for 2024/25.
There will be an overall increase in investment of £44m in 2024/25. This assumes:
- 2% pay growth uplift to the overall Additional Roles Reimbursement Scheme (ARRS).
NHS England will suspend and income protect 32 indicators (out of the 76 QOF indicators) and align indicators CHOL002 with the new NICE NM252 indicator definition of cholesterol control.
GPCE requested that aspiration payments for QOF were increased as part of the move towards a higher trust model (currently 70%). This was accepted and NHS England propose increasing aspiration payments from 70% to 80%.
The value of a QOF point for 2024/25 is £220.62.
NHS England will streamline eight clinical specifications into a single higher trust specification (with some detailed specification requirements moved to guidance documents).
They will also simplify the role requirements for PCN Clinical Directors, focusing on requirements for delivery of modern general practice and allocation of resources and accountability to the ICB. There will be a more flexible funding pool for PCNs by rolling the Clinical Director and PCN Leadership and Management into core PCN funding (£183m).
NHS England will streamline the IIF further and redirect funding to CAP (Capacity and Access Payment) funds amounting to £292m for 24/25. The IIF will be reduced from five indicators to two - worth £13m – with only the indicators on learning disability and FIT testing retained.
PCNs and GP practices will be allowed to agree with ICBs (integrated care boards) the deployment of any doctor that is employed or registered with bodies designated by the Medical Profession (Responsible Officers) Regulations 2010 (Schedule, Part 1 only) to deliver primary care services without being on the Medical Performers List. There will be a corresponding change to the GP contract regulations.
- These changes will permit GP practices and PCNs to employ doctors who are already employed, for example, by an NHS trust or NHS foundation trust without the requirement for the doctor to also be registered on the MPL.
- Supporting guidance will also be issued to clarify that non-GP doctors should not see undifferentiated patients and that they continue to be required to operate within their sphere of competence.
NHS England will now:
- Include enhanced practice nurses in the roles eligible for reimbursement.
- PCNs will be able to recruit other direct patient care non-nurse and non-doctor MDT roles, if agreed with their ICB.
- Where PCNs already have one mental health practitioner (MHP) in place, 50:50 funded by the PCN and the mental health provider, funding arrangements for subsequent MHP roles will be for agreement between the PCN and the mental health provider, subject to ICB approval.
- Caps on advanced practitioners will be removed.
- PCNs will be able to claim reimbursement for the time personalised care roles spend out of practice undertaking training or apprenticeships to obtain a level three occupational standard.
- Allow reimbursement of training time for personalised care roles undertaking training or apprenticeships.
NHS England will make the following changes:
- 70% CASP (Capacity and Access Support Payments) monthly with no reporting requirements
- 30% CAIP (Capacity and Access Improvement Payments) payable on PCN confirmation that PCNs have put in place all components of the Modern General Practice Access model
- Digital Telephony data reporting: practice-level reporting of call data to commence October 2024
- Online patient registration process as well as paper registration
- Digital copy of practice boundary using NHSE mapping tools
- Strengthen reference to ‘continuity of care’ as a criterion when considering response to patients initially contacting the practice
NHS England will expand the shingles cohort to as part of the 10-year expansion of the programme, in line with JCVI advice. The expansion of the immunocompetent cohort is proposed for implementation over two five-year stages as follows, with the first years having been confirmed:
- First five-year stage: Shingrix will be offered to those turning 70 and those turning 65 years of age in each of the five years as they become eligible.
- Second five-year stage (subject to confirmation of funding): Shingrix will be offered to those turning 65 and those turning 60 years of age in each of the five years as they become eligible.
NHS England will also change the current V&I standards including:
- Shared data on vaccination status of patients with local CHIS [Child Health Information Services]
- Rationalisation of SNOMED codes used for vaccinations to improve data quality
- Improved data recording of vaccination status (including new patients registered from overseas)
- Practices must amend data they are informed is incorrect.
NHS England will continue this for 2024/25 with an unchanged IoS (item of service) payment of £11.50 and a capped total funding of £7.2 million.
NHS England will require practices to have ‘due regard’ for the needs and circumstances of Armed Forces Veterans when offering services and making referrals.
A minor amendment to the wording in regulations to update reference to Digital Primary Care: Good Practice Guidelines for GP Electronic Patient Records: Version 5 will occur.
GPCE solutions rejected by DHSC and NHSE
How much additional funding did GPCE ask for for 2024-25?
The Government / NHSE themselves coined 2024-25 as a ‘stepping stone’ year, which was meant to provide a stable foundation for more substantial positive reform from 2025-26 and beyond. We therefore provided evidence simply demonstrating the impact of inflation on the erosion of the real-term value of the core practice contract baseline funding in recent years. For the uplift offer to amount to so little (£179m for GP and practice staff pay) in the context of such significant inflation, it is unconscionable that practices can absorb this without losing staff or becoming unviable.
The cost of GP and practice staff pay erosion since 2008/9 is even greater, so that needs to be addressed this year.
- 8.7% increase for Contractor GPs, salaried GPs, other employed staff and other practice expenses just to keep pace with 21.2% CPI inflation between April 2019 – April 2023.
The 2019-24 contract investment grew by 12.5% across the five years. - This would have increased the overall core practice contract funding baseline (Global Sum) by £799m from £9.2 billion to around £10 billion.
- Further uplifts to then be applied as necessary following the 2024/25 DDRB Award (expected in June / July) to ensure guaranteed fair pay uplifts for salaried GPs and other practice-employed staff.
- Amendment of Personalised Care Adjustment to take account of informed dissent for childhood vaccinations citing data from affected deprived cohorts and atypical populations.
- Item of service fee for all SFE (Statement of Financial Entitlements) Para 19 vaccinations and immunisations to increase in line with CPI inflation (21.2%).
- An increase in line with CPI inflation (21.2%)
- These rates have not changed since 2019/20.
- Providing an uplift to core practice baseline funding to enable practices to cover salaried GP expenses as a way to boost income before tax after such significant cost-of-living increases in recent years.
This can be legally implemented by practices using the BMA’s Safe working in general practice guidance and doing so does not breach your contract. The BMA’s salaried GP model contract is the existing and recommended vehicle here for limiting hours / sessions to safe levels and, legally, terms no less favourable should be offered by GMS/PMS practice employers.
BMA members also get access to free contract checking services and are strongly encouraged to use them.
- DHSC / NHSE were warned of the additional cost of full salaried GP pay restoration (compared to 2008/9 levels) during the discussions.
- These practice-employed staff pay uplifts need to be guaranteed by Government / Treasury.
- GPCE/conference position – move QOF funding into core practice funding
- QOF 70% payments to be increased to 90% upfront given 20-year body of evidence to draw on and challenging NHS England to return with evidence.
- End the DES and move funding into the core practice funding baseline
- Allow practices to use a proportion of enhanced access appointments for continuity of care for their own registered patient lists
- Rewind and refresh the central tenets and purposes of PCNs to support constituent practice workload
- Retire IIF indicators from 5 to 1 (HI03) – retire CAN02
- Pay the 30% CAIP (Capacity and Access Improvement Payments) upfront, without dependence on dysfunctional ICB budgets to support requested IT solutions
- Mandate PCNs/practices to use ringfenced proportion of CAP funding for GP supervision of ARRS staff
- Recycle a ringfenced proportion of the CAP to fund a national Safeguarding DES
- Mandate use of CAP monies to increase Care Home Premium payment to £12 per month/£144 per year
- Protect the GP status/requirements of PCN CDs (£44m)
- Recruitment of GP Nurses
- Recruitment of GPs with extended roles
- Allow PCNs to best match the needs of the registered patient population against local recruitment challenges
- Budgets to be drawn down from ICB allocations to ensure oversight of ‘additionality’ and spend against recruitment
- No Consultants, no Staff Grades or 'Primary Care Doctors'
- Allow initial MHPs/Paramedics to be outside host Trust arrangements
- Better NWRS (national workforce reporting system) scrutiny.
- 85-90% CASP (Capacity and Access Support Payments) monthly with no reporting requirements.
- 10-15% CAIP (Capacity and Access Improvement Payments) payable on PCN confirmation that PCNs have put in place all components of the ‘Modern’ General Practice Access’ model.
- Cloud-based telephony data reporting: PCN/Place-level aggregated reporting.
We suggested training hubs be encouraged to develop recruitment and retention programmes for Trust-based roles seeking to transition into the primary care setting – specifically nursing roles, but not exclusively.
We proposed that NHSE mandate ICBs to commission a service level agreement from Trusts of Occupational Health support to all NHS GP staff and contractors. This could have been subcontracted at a system or place level. That would lead to greater productivity of the primary care workforce, and greater efficiency at scale, levelling up access to occupational health, improving outcomes for the workforce and embedding integration of wider partnership mutual aid across the ICB footprint from existing Trust budgets.
GPCE requested a public commitment to setting up a task group to investigate enabling amended regulations for 25/26 to permit GMS/PMS partnerships to limit their liabilities. DHSC agreed to look at this in the coming year.
GPCE proposed a relaunch and refresh of the New to Partnership Programme, including eligibility to all those GMS/PMS partners joining a partnership from 1 April 2023 onwards, so long as they remain in post for a minimum of 24 months. The proposal included a golden hello payment weighted to deprivation indices, and a £1,000 budget to draw down on funding practice business fundamentals training to spend from 1 April 2024. The Primary Care Minister has discussed looking into this with us.
GPCE requested a limit to the routine CQC inspection window from April 1 – September 30 to allow primary care providers to focus on prioritising patient access and same day urgent care during periods of increased system pressure over the winter months. From October 1 – March 31 inspections should be restricted to those where concerns have been specifically flagged to the regulator, commissioner or LMC. DHSC/NHSE suggested this is taken up with CQC directly.
Why it matters
The future of general practice services is relevant to all GPs and GP registrars in England. Whether you’re:
- already struggling to deliver your service contract
- struggling to keep up with the workload, regular unpaid overtime as a salaried GP and/or insufficient annual pay uplifts to match inflation
- cannot find enough / any work or cannot find work with fair working conditions as a locum GP
- having your training time ruined because you are regularly being asked to contribute to service delivery beyond your contractual requirements
- have reluctantly left NHS practice and work in the private sector because of the terms and conditions on offer
we invite you to consider these contract changes from your own perspective as well as those of your colleagues and your patients.
It is from the investment in this contract that working conditions and pay are derived for all GPs and practice-employed staff. GP Registrars may have a different training contract, but they will become qualified GPs in the not-too-distant future. Every missed opportunity to improve the GP contract means it will take us longer to get things back to a place where work is safe and patient care is safe and of the quality they deserve. Check out the BMA’s general practice pressures data analysis page to see how hard we work as a profession but how far away we currently are from safe practice and GPs numbers.
Received your practice's e-contract variation and not sure if you should sign it?
Contract variation notices are just that. The imposed changes will come into effect after the specific notice period ends with or without a signature.
The significance of the Government’s use of the GDP deflator inflation measure forecast rather than CPI (used for the 2019-24 contract)
The GDP deflator and CPI are both measures of inflation. However, CPI is a measure of consumer price inflation (that’s what CPI stands for) whereas GDP is a wider measure of inflation that includes goods and services bought and sold by the Government, as well as business investment spending among other things.
Inflation as measured by the GDP deflator tends to be lower than CPI. The latest forecasts suggest CPI increased by 21.7% between 2019/20 and 2023/24, whereas the GDP deflator only increased by 19.0%. So the Government using the GDP deflator means that the contract looks like it has fallen less in real terms than it would using CPI.
Using the GDP deflator is inappropriate for the GP contract. CPI is more appropriate because many of the things included in the GDP deflator are not relevant to the GP contract, and the biggest part of the GP contract – staff wages – should be linked to a measure of consumer inflation not the GDP deflator.
Key considerations
Thinking about safety, stability and hope for the coming year and beyond:
- How will the contract ensure the funding available to you enables recruitment/retention of sufficient staffing?
- How does the contract support you to maintain and or develop your practice premises?
- How will the contract ensure safe working practices around hours?
- How will the contract ensure safe working conditions?
- How will the contract safeguard GP contractor / partner members in providing safe patient care?
- How will the contract address issues around home visits and ensuring effective working patterns for GP contractors / partners?
- How will the contract ensure improved working practices around appointment times?
- Does it guarantee sufficient funding to ensure all GP contractors/partners can receive the annual Doctors’ and Dentists’ Review Body pay award?
- Does it guarantee the protection of necessary CPD (continuing professional development) time that all GPs need?
- Is sufficient funding available to ensure GPs have the tools to deliver healthcare in the 21st century?
- How will the contract ensure safe working practices around hours?
- How will the contract ensure safe working conditions?
- How will the contract safeguard salaried GP members in providing safe patient care?
- How will the contract address issues around home visits and ensuring effective working patterns for Salaried GPs?
- How will the contract ensure improved working practices around appointment times?
- Will the contract deliver sufficient funding to ensure salaried GPs are paid fairly and have terms no less favourable, as required by the contract regulations, than the BMA salaried GP model contract?
- Does it guarantee sufficient funding to ensure all salaried GPs can receive the annual Doctors’ and Dentists’ Review Body pay award?
- Does it guarantee the protection of necessary CPD (continuing professional development) time that all GPs need?
- Is sufficient funding available to ensure GPs have the tools to deliver healthcare in the 21st century?
- Will the contract ensure funding for future job opportunities?
- How will the contract ensure safe working practices around hours?
- How will the contract ensure safe working conditions?
- How will the contract safeguard locum GP members in providing safe patient care?
- How will the contract address issues around home visits and ensuring effective working patterns for locum GPs?
- Will the contract ensure funding to ensure GPs entering the workforce are paid fairly within the sessional model / locum model?
- Does it guarantee the protection of necessary CPD (continuing professional development) time that all GPs need?
- Is sufficient funding available to ensure GPs have the tools to deliver healthcare in the 21st century?
- How will the contract ensure safe working practices around hours?
- How will the contract ensure safe working conditions?
- How will the contract safeguard GP registrar members in providing safe patient care?
- How will the contract address issues around home visits and ensuring effective working patterns for GP registrars?
- How will the contract ensure improved working practices around appointment times?
- How will the contract protect/support registrar GPs in ensuring a smooth transition to becoming a fully qualified GP?
- Will the contract ensure funding for future job opportunities?
- Will the contract ensure funding to ensure GPs entering the workforce are paid fairly within the sessional model/locum model?
- Will the contract facilitate the availability of GP registrar training places?
- What benefits can ST1-3s expect as a result of the contract changes?
- Is sufficient funding available to ensure GPs have the tools to deliver healthcare in the 21st century?
- How will educational opportunities be affected/protected by this new contract?