Sefton LMC Collective Action Toolkit – Introduction
Following the recommended tactical pause, Sefton LMC is now encouraging GP practices to implement collective action in furtherance of the GP contract 24/25 dispute. This toolkit contains advice and templates to help practices implement the Phase 1 menu of collective actions, and shows the steps we are taking to support practices with the actions, including communications with other providers.
The General Practitioners Committee of the BMA (GPC) has asked practices to take action on any element or all of its collective active menu; these are shown below:
- Limit daily patient contacts per clinician to the UEMO 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 for you it is a timely and clinically helpful process in your professional role.
- Serve notice on any voluntary services currently undertaken that plug local commissioning gaps and stop supporting the system at the expense of your business and staff.
- 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 two-week wait (2WW) appointments, but outside of that write a professional referral letter in place of any locally imposed proformas or referral forms where this is preferable. It is not contractual to use a local referral form/proforma – quote our guidance and sample wording - Switch off GPConnect Update Record functionality that permits 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 (i.e. not direct care). Read our guidance on GP data sharing and GP data controllership.
- Freeze sign-up to any new data sharing agreements or local system data sharing platforms. Read our guidance on GP data sharing and GP data controllership.
- 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).
- Defer signing declarations of completion for “better digital telephony” and “simpler online requests” until further GPC England guidance is available. In the meantime:
– “Better digital telephony”: The contract variation notices ICBs sent in August mean you are contractually required to have enabled data extraction by 1 October 2024. Read the GPCE update.
– Defer signing off “Simpler online requests” until Spring 2025: do not agree 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 NHSE Pilot programmes whilst we explore opportunities with the new Government.
Our survey of practices preferences shows that the majority of Sefton practices favour taking action on the majority of the options. Please let us know about any difficulties you meet in taking action, e.g. rejection of referrals or claims that you have a contractual obligation to comply.
Please ensure your whole practice team is aware of the actions that practice is taking and what they need to do to support these. This toolkit is also available via our website https://seftonlmc.co.uk. Please join our GP Contract WhatsApp group to be rapidly updated on developments and GPC announcements.
Sefton LMC Collective Action Toolkit – Action 1
Limit daily patient contacts per clinician to the UEMO 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.
The first action is perhaps the most difficult – limiting to 25 patient contacts per clinician per day (although some practices in Sefton have been able to achieve this). What constitutes a patient contact, particularly if a practice uses total clinical triage?
Therefore, LMC feels that this is the action where it is most difficult to offer directive advice & support, because practices have such a variety of clinical models. Also, we recognise that practices often have a variety of contractual arrangements in place with the clinicians in their teams.
However, we feel that moving towards limiting patient contacts in accordance with the BMA safe working guidance is about just that – safe working.
https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-in-general-practice
So irrespective of the collective action, we would encourage practices to consider ways of incorporating that guidance into their clinical models. Think about all the occasions where you take a clinical action in response to an abnormal result, or a call/ letter/ email from another service – this is a clinical contact and should be included within your appointment system, rather than dealt with as an extra.
As the winter pressure period approaches and the likelihood that practices will be encouraged to make additional appointments available increases, we would encourage practices to take a ‘do no harm’ approach to their clinical capacity. Please consider signposting patients to other appropriate services if they require urgent care & your capacity is stretched.
Sefton LMC Collective Action Toolkit – Action 2
Stop engaging with the e-Referral Advice & Guidance pathway – unless for you it is a timely and clinically helpful process in your professional role.
Action 2 is to stop engaging with eReferral advice & guidance (A&G).
Practice partners are at liberty to insist their clinicians & trainees stop using A&G completely. However, the majority of local colleagues intend to continue using it when they require ‘advice & guidance’ only. This was the crux of the action anyway; that A&G should not used in place of a ‘standard’ referral, because it can lead to un-resourced transfers of care from secondary to primary care. Also, practices remain medicolegally responsible for the advice given if they agree to follow it.
The LMC is writing to all local trust medical directors, to explain that if a practice makes a standard referral, including a ‘refer for triage’, they are not asking for advice & guidance; they are discharging their professional, medicolegal & contractual responsibilities to refer. Rejecting the referral & offering clincial advice in its place is not acceptable – the Walton Centre advising to ‘follow the headache pathway’ is one example.
You may wish to attach the following ‘transfer of care’ document to all of your referrals, which helps to explain this (amongst other things):
Transfer of Care – Referral Letters v1.2
Alternatively, you may wish to add the text below to your referral to confirm you do not want your referral to be treated via advice and guidance and that it should not be rejected because of this:
I am providing the necessary and relevant information for an appropriate request for a secondary care service, which conforms with the NHS Standard Contract 2024/25 Service Conditions. This referral is not a request for clinical advice so please do not reject this referral & offer clinical advice in its place as it may result in unnecessary delay or harm to the patient.
More information about the collective action being taken by GP practices and the challenges they face can be found at:
Sefton LMC Collective Action Toolkit – Action 3
Serve notice on any voluntary services currently undertaken that plug local commissioning gaps and stop supporting the system at the expense of your business and staff.
When we have looked at lists of un-resourced activities that have been prepared by the BMA/ other LMCs, it is reassuring to see that Sefton is in a relatively favourable position. For example, many of these activities are resourced via the Sefton Local Quality Contract for GP (LQC) or there are other community services in place to provide them.
The three that were identified during our LMC open meeting in September 2024 are as follows:
- Shared care prescribing for dementia drugs: this is the only shared care arrangement in Sefton that is not resourced via the LQC. Some colleagues have suggested that their practice would just start declining new requests for dementia shared care, so the LMC has advised Mersey Care that this may commence with immediate effect. For practices who wish to withdraw from historic agreements too, the LMC would suggest that a reasonable period of notice is given; say 12 weeks. A proactive communication to patients would be important too, with a safe and orderly transfer of care being the absolute priority. Mersey Care have asked if the practice could write to the respective consultant & Cc. their emergency planning team (planning@merseycare.nhs.uk), along with the following information [this could be provided in the form of a spreadsheet listing all affected patients]:
- Details as to when the next prescription will be required
- Confirmation if any blister pack preparations are required
- Receipt of clinical requests by email, including from Mersey Care community teams. Colleagues seemed keen to have a standard auto-response wording on their practice email accounts, stating that they do not accept transfers of care by email. The LMC has contacted Mersey Care and asked them to inform their teams that such requests should be made by direct telephone contact with a practice clinician. The LMC feels that practices should give them at least until the end of the month to mobilise this change. Our suggested auto-response wording is as follows
- Child safeguarding collaborative work, including MASH information sharing: practices would be at liberty to invoice for this work in accordance with the BMA advice below. However, according to our WhatsApp polls about the collective action, practices were not keen to seek payment via legal means if their invoice was not paid. Instead, there was an appetite for the LMC to prepare a letter to the ICB for practices to countersign, stating that this work is supposed to be funded, so if this ongoing situation is not resolved before the end of this fiscal year, practices may start submitting invoices for it. The LMC will prepare this letter and share it with you as soon as possible.
Nevertheless, a substantial volume of non-contracted/ unfunded work is already undertaken by GP practices, and there are expectations in some secondary care/ other agencies that GP practices are a back stop for all work that is inconvenient to them. Some examples are as follows:
- Being asked to re-refer after an interval; e.g. for endoscopy, echocardiogram
- Fit notes following operations/ hospital stays
- Phlebotomy requested by secondary care
- PSA/ MGUS monitoring requested by secondary care
- Requests from secondary care for onward referral
- Inappropriate prescribing requests from secondary care and other providers
- Requests to follow up investigations performed in other settings
- Requests for post-operative checks
- Re-referring patients after a missed appointment
- Requests to advise a patient of something; e.g. a test result
- Requests for work absence sick notes for less than seven days
- Requests for triple therapy from gastroenterology
- Requests to action MSSU and swab results from antenatal midwives,
- Ferrous fumarate requests by midwives
- BP monitoring prior to 6 weeks postnatal when a patient has been treated for pregnancy related hypertension
- Repeat CXR requests following a discharge from hospital
- Actioning abnormal, non-incidental findings at a pre-op clinic
A template letter that you may choose to use to reject such requests is as follows:
CA template autoresponse email
I refer to your request for this practice to undertake …………. (insert work requested]. I enclose a copy of your request (optional). We are unable undertake this work for one or more of the following reasons:
- The task(s) is not an essential service as per our GMS/PMS contract
- This work has not been commissioned by our ICB
- This work has not been funded as a national or local enhanced service
- This work is more appropriately provided by yourself as a specialist
You will be aware of the current pressures on general practice, and the present dispute between general practice and the Dept of Health over the imposition of an inadequate GP contract 24/25. We unable to undertake un-resourced or inappropriate work that is outside our contractual responsibility, and which might compromise our core duty of care to patients.
We have informed the patient that this work is not the responsibility of the practice and we would be grateful if you would contact them directly to provide the service.
Thank you for your understanding.
Sefton LMC Collective Action Toolkit – Action 4
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 two-week wait (2WW) appointments, but outside of that write a professional referral letter in place of any locally imposed proformas or referral forms where this is preferable. It is not contractual to use a local referral form/proforma – quote our guidance and sample wording
Action 4 speaks for itself; however, the main area for us to consider is referral proformas. Whilst using these is not a professional or contractual requirement, there are two exceptions to this: the Cheshire & Merseyside Urgent Suspected Cancer (2WW) referral proformas and the memory clinic referral proforma, where using these is a requirement of the Sefton Local Quality Contract for GP (LQC).
Some practices in Sefton are planning to use referral proformas still on an ad hoc basis, when it suits them to do so; some are planning to stop using the non-contractual ones completely. Whilst the BMA has prepared some sample wording to use on professional referral letters that are being sent in place of a referral proforma, the LMC has prepared the following ‘transfer of care’ document, which you may prefer to send with all of your referral letters instead:
Transfer of Care – Referral Letters v1.2
This document explains why a referral proforma has not been used and it may help to enforce a number of other messages about transfers of care at the primary-secondary care interface.
As stated in action 2 from this toolkit, Sefton LMC is writing to all local trust medical directors (or equivalents) about the collective action – this will mention referral proformas and the fact that GP practices may now be referring via a professional referral letter instead. We will also discuss this at the North Mersey Primary-Secondary Care Interface group. NB, GP practices are not required to provide specialists with all the information they might require to triage a referral, if this was not part of the GP practice’s own assessment of the patient. If needs be, specialists can contact patients themselves to request further information
The LMC has already written to Mersey Care, asking them to make their teams aware that practices in Sefton may soon stop using their many referral proformas, and they have acknowledged receipt of this correspondence.
Sefton LMC Collective Action Toolkit – Actions 6 & 7
Withdraw permission for data sharing agreements that exclusively use data for secondary purposes (i.e. not direct care).
Freeze sign-up to any new data sharing agreements or local system data sharing platforms.
- Read our guidance on GP data sharing and GP data controllership.
In our WhatsApp polls about actions 6 & 7, there was a mixture of opinions from colleagues about how to proceed with these.
Combined Intelligence for Population Health Action (CIPHA) is a data sharing platform that most practices in Sefton have signed up to. It appears to have been rebranded as ‘Data Into Action’, with CIPHA being a part of their ‘Secute Data Environment’: https://www.cipha.nhs.uk
This data sharing platform has a number of workstreams. Previously, Sefton LMC has supported the Population Health and Covid Intelligence workstreams. We did not support the Direct Care workstream, due to concerns about the scope of its sharing and because the role-based access controls contradicted our own local direct care EMIS data sharing agreements. Also, we did not support the Research workstream, not least because we were aware of the impending collective action, so we believe Sefton practices were never approached to request their sign-up to this workstream.
For practices who wish to withdraw from the CIPHA Population Health workstream, you can do so by emailing cipha@merseycare.nhs.uk. You would need to ask for all data processing for data subjects at your practice to cease, & for their data to be removed from the platform. NB, this agreement is used for some work with high intensity service users that is taking place in Sefton, which would not be possible without it.
The LMC is not aware of any other local data sharing agreements that exclusively use data for secondary purposes; i.e. not direct care.
The Sefton Local Quality Contract for GP (LQC) contains a clause stating ‘practices should activate data sharing agreements that have received local relevant approval (i.e. by iMerseyside & Sefton LMC) within 4 weeks of issue, or escalate any issues within that 4 week period’. The LMC will continue to review new/ updated sharing agreements before they are sent to practices. In future, it is highly unlikely that the LMC would support any agreement that did not have a strong use case for direct patient care, and we will be opposing any use of data for secondary purposes being incorporated into local data sharing agreements. Therefore, we do not anticipate that this clause will act as a barrier to this collective action.
Sefton LMC Collective Action Toolkit – Action 8
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).
Action 8 relates to the use of ScriptSwitch software for medicines optimisation.
There is no national or local contractual requirement to use ScriptSwitch. However, it can help with safe prescribing & help practices to achieve the medicines optimisation Key Performance Indicator (KPI) within the Sefton Local Quality Contract for GP (LQC). One of the components of this indicator is:
At least 25% of new prescriptions in our targeted QIPP areas are for the preferred choice, in line with prescribing support software.
This is worth approximately 50p per weighted patient to practices so understandably, in our WhatsApp polls about the collective actions, there was little appetite from colleagues to disengage from these targeted QIPP areas completely.
Cheshire & Merseyside ICB is facing a massive financial challenge and optimising their prescribing costs is one way that they might hope to meet this challenge. Therefore, if practices across the region were to disengage with these targeted QIPP areas (or even select more expensive branded drugs deliberately), this could be a very visible and effective form of collective action initially. However, this might leave even less money available for discretionary schemes like our LQC, so such action could well backfire.
In summary, if practices are planning to continue to engage with the targeted QIPP areas and they can see the benefits of ScriptSwitch for safe prescribing, then turning off ScriptSwitch is unlikely to achieve very much in reality. Nevertheless, the following document summarises the targeted QIPP areas that were in place at the start of the fiscal year, which may help practices achieve the LQC KPI if ScriptSwitch is turned off:
NB the targeted QIPP areas are subject to change throughout the year, and neither The Corner Surgery nor Sefton LMC accept responsibility for the accuracy of the above document, if it is used by another practice.
Sefton LMC Collective Action Toolkit – Actions 5, 9 & 10
Switch off GP Connect Update Record functionality that permits the entry of coding into the GP clinical record by third-party providers.
The LMC advised practices to undertake action 5 before the outcome of the collective action ballot was known, so we expect that any practice who wished to turn off this functionality has already done so. If not & you require further advice about this, please email seftonlmc@seftonlmc.co.uk.
Defer signing declarations of completion for “better digital telephony” and “simpler online requests” until further GPC England guidance is available. In the meantime:
– “Better digital telephony”: The contract variation notices ICBs sent in August mean you are contractually required to have enabled data extraction by 1 October 2024. Read the GPCE update.
– Defer signing off “Simpler online requests” until Spring 2025: do not agree to keep your online triage tools on throughout core practice opening hours, even when you have reached your maximum safe capacity.
Action 9 speaks for itself. Please note the GPC update re: better digital telephony above.
Defer making any decisions to accept local or national NHSE Pilot programmes whilst we explore opportunities with the new Government.
Action 10 speaks for itself. The LMC will be cognisant of this action in any relevant communication with the commissioners.
