The GP contract talks have been played out for the public, with both sides taking to the airwaves. Ingrid Torjesen explores why a couple of extra hours a week has created such a conflict
Two weeks ago there seemed to be a breakthrough in the deadlock over negotiations to extend GP opening hours. After a public slanging match, which had seen the British Medical Association accuse the government of not caring about quality care, at a special meeting the union's GPs committee all but advised doctors to accept the offer NHS Employers made in December. It will now poll its members for a formal decision.
The committee considered it the least damaging route for general practice and everyone began to hope that the rift between the BMA and the government would start to heal.
But overnight the committee changed tactics. The next day it emerged it was advising practices they were within their legal rights to withhold data on opening hours that the Department of Health had requested primary care trusts to collect.
This has not impressed the government. Last week, health minister Ben Bradshaw told HSJ: "Such a request from the local health services is perfectly reasonable and I am saddened that the BMA appears to be adopting such tactics when we were looking forward to rebuilding relationships with them after they changed their mind and decided to support our proposals."
But will it be possible to rebuild those relationships? Feelings have clearly been running high on both sides. The day before the special committee meeting two weeks ago, its chairman, Laurence Buckman, sounded strained. He accused the government of wanting to take "revenge" on GPs for negotiating generous terms under the general medical services contract implemented in 2004.
"This sounds to us like punishment. This sounds to us like revenge on GPs for having the nerve to have earned money out of a new contract that the government designed and was signed off by the chancellor of the exchequer at the time - Gordon Brown."
He said he felt the committee had negotiated a deal acceptable to NHS Employers, but the government had interfered. The end result was that the BMA was now facing a public backlash on the one hand and a vocal subsection of GPs who felt it was not taking a hard enough line on the other.
"A majority of GPs were willing to offer extended access to patients. And we believed we had a deal on the table which not only did that but also offered better quality clinical care for patients within existing resources," Dr Buckman said.
Although the deal was not sealed, "there was an understanding that there was a following wind", he added. "We were at the point of saying let's get it organised for April, and then suddenly the government said it was not good enough."
The government wanted more time and for it to be "delivered in an inflexible manner that responded to a promise that Gordon Brown had made", Dr Buckman said.
NHS Employers deputy director Alastair Henderson denies this: "We don't accept that there was a deal made that was then changed. There is a well-known and loved phrase in negotiations that nothing is agreed until everything is agreed," he says.
When the situation came to a head in December, the main sticking point seemed to be that the government wanted three extra hours from an average practice per week, whereas the committee wanted only two.
Dr Buckman says this was not the case. "We are certainly not going to have a fight with government over one hour. The argument was always about flexibility, it was never about two hours versus three."
The issue was around having to provide an extended service in one and a half hour blocks when GPs who offered extended hours did so flexibly, by being available when a patient asked to be seen at an unusual time, Dr Buckman says.
"Sitting in a surgery for a period of time so that I can fulfil a political target rather than a patient need target seems to me to be strange."
Asked about what he thinks of the way the BMA has handled the negotiations, Mr Bradshaw says it is a matter for its members. But he adds: "It is clear from [health secretary] Alan Johnson's decision to write directly to GPs that we felt there were weaknesses."
Mr Johnson wrote to GPs "because of a concern he had that the information being given out by the BMA leadership was not really an accurate or fair reflection of the details of the discussion", Mr Bradshaw explains.
"The BMA still has its way of doing things and we respect that. Whether it has proved to be sensible or constructive in this whole process is not something for us to judge, it is something for the medical profession to make a judgement about."
BMA chairman Hamish Meldrum, who has not been involved in the extended hours negotiations, is reluctant to discuss them. But when pressed he is clear that he wants to see an end to the "megaphone diplomacy".
"A war in the long run serves nobody any good purpose. It doesn't do doctors any good, doesn't do the government any good and most of all it doesn't do patients any good."
But he warns the BMA's members are not "just going to be pussycats and lie and have our tummies tickled. We will react and of course we will be fairly robust and strident when we feel the government is trying to take advantage of us and trying to renege on agreements."
He believes the problem is that some people in government feel the BMA "pulled some fantastic trick" on the general medical services contract and have been trying to claw that back. This has left GPs feeling "embattled".
Does the government want rid of the BMA? "There are people in government who would want to do that, just like there are people in the medical profession who would like to get the government right out of the NHS. But I would hope that those who are sensible in government, and I think there are still quite a few, would see that trying to work withƒ representatives of the profession in the long run brings you far more dividends than breaking them."
However, he will not be drawn on whether a clash of personalities between the leaders of the two negotiating sides has contributed to the difficult situation. "You have to get around personality and try and focus on the issues."
The government made it clear in December that if the deal is not accepted by GPs it will impose more punitive arrangements on them. Mr Henderson says the government was "prudent" to do this because of the 13-week consultation period required.
"If they had not done and waited to the end of February when the ballot was over, there could have been criticism the position wasn't clear. Certainly there wouldn't be clarity for PCTs about what was happening."
Mr Bradshaw says the DH has made the deal more flexible and that is one of the reasons why the committee "changed their minds and decided they would support the proposals after all".
"Of course for a long time they did insist on no more than two hours [per average practice per week], so they have moved their position, which I welcome. I think it reflected a growing feeling on the ground that GPs are willing and prepared to do this."
The NHS operating framework has set PCTs a target of 50 per cent of practices offering enhanced hours. Tower Hamlets PCT in east London has proved it is possible to work with GPs not only to meet but to surpass that target. Only one practice out of 36 does not offer the service.
Andrew Ridley, director of primary care at Tower Hamlets, says: "Our experience shattered a few myths about who extended hours are for."
One of the first practices to offer extended hours in the morning was near Canary Wharf and they thought it would be full of yuppies, he says. "They were actually full of hourly paid manual workers who lost money if they didn't go to work and who came in at seven in the morning and were dead chuffed."
He believes the government would do better to leave extended hours for PCTs to negotiate locally. Tower Hamlets PCT pays practices£120 for six appointments and allows them to choose when they want to provide extra hours. As a result, he says practices have been keen to be involved.
While the key players in the negotiations will not make predictions on the outcome of the GP ballot, NHS Alliance chair Michael Dixon is optimistic GPs will vote for the deal because they will not want to prolong the dispute any longer and think it will be better for them financially.
However, he is concerned that the dispute is holding up reform on the ground. "If you talk to a lot of PCT modernisation and redesign managers, they will say it is difficult in some areas to engage with GPs because they are so angry with the way they feel they are being treated. They are almost tarring PCT managers with the same brush and they are not wanting to contribute.
"In many cases they are distracted, thinking about what is going on in their own practices and wanting to make sure they are maintaining income, service and all the rest of it."
Northamptonshire teaching PCT director of commissioning Richard Alsop admits that the situation has slowed development of extended access plans there. A third of practices have expressed interest, but others want to wait for the outcome of the national vote.
"It is causing a bit of frustration and a slowing down of the implementation plans," he says. "I think it might have implications when we come to the final settling and signing off of the whole range of enhanced services, because we like to see them as a package and I think practices do too."
PCT Network director David Stout says the only problem most PCTs face now is not being able to finalise discussions on extended hours. The real difficulties will come if GPs reject the national deal.
The operating framework target of 50 per cent of practices providing extended hours will be "relatively easy" to meet if the deal goes through, Mr Stout says. "If we get to a position where the deal is not signed off and something is imposed, that is going to make implementation at local level by PCTs quite difficult.
"They are going to have to negotiate what wasn't agreed at national level. If the whole profession is in a very negative mood, I just think it is going to make that more difficult. That is not to say it is impossible. It may be local relationships are much stronger than national ones."