It is hardly Margaret Thatcher versus the miners, but the industrial action GPs are about to take in Northern Ireland is still a fascinating contest of politics, economics and social class.
Most general practices throughout the UK are private businesses, owned and run as partnerships. They supply primary care to the National Health Service under a standard contract, renegotiated every financial year between ministers and the general practice committee of the British Medical Association (BMA) – in effect, the GPs’ trade union. This happens separately in each of the four parts of the UK.
GPs in Northern Ireland are unhappy with this year’s contract and voted overwhelming in May to reject it, expecting it would be reopened.
Instead they were told to take it or leave by Mike Nesbitt, Stormont’s Minister for Health and leader of the Ulster Unionist Party.
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The BMA had three demands in negotiations: funding for liability insurance, funding to offset a tax rise and a 20 per cent increase for primary care funding overall. In a forthright statement to the assembly in May, Nesbitt said he had met the first two demands, the BMA would not explain why it was claiming otherwise, while the third demand was plainly impossible. He stopped short of accusing the union of bad faith but the implication was difficult to avoid.
The BMA was furious and began consulting members on action short of a strike, or working to rule, as it used to be called. GPs approved this last week in another overwhelming vote. Actions will include ignoring unessential paperwork, withdrawal of noncontractual services and limiting appointments to the recommended safe limit of 25 per day. This is likely to disrupt tests and treatments co-ordinated between GPs and hospitals.
Nesbitt still will not budge. He has enraged the BMA further by saying he is willing to talk – but only about next year’s contract.
Nesbitt has linked contract negotiations to the poor service he alleges GPs are providing
Although this stand-off is unprecedented in Northern Ireland, an almost identical dispute has just played out in England. GPs there rejected their contract last August, then voted for action short of a strike in February – the first time they had done so in 60 years. The government backed down weeks later.
Northern Ireland’s GPs might expect a similar retreat by Stormont, but that is far from certain. Mandatory powersharing turns departments into silos and Nesbitt is his party’s only minister. If he wants to dig his heels in, he is free to do so.
The UUP has not been a team player at the executive, objecting to the budget and criticising Sinn Féin finance ministers over allocations for health. Yet Nesbitt has taken a very different approach to the GP dispute, portraying the BMA’s demands almost as a personal affront. He insists he has extracted as much cash as possible for health, so it is absurd to demand 20 per cent more.
Despite terrifying the UK government, the prospect of a GPs’ strike could be considered a bluff. As private businesses, practices cannot stage an all-out strike in the usual sense of the word. They can only hand back their contracts and shut down. Options to move into the private sector or take on private patients are limited, at least so far. The annual nature of contracts means Nesbitt only has to sit tight for a few more months to win this year’s dispute by default.
Beginning with his Assembly speech in May, Nesbitt has linked contract negotiations to the poor service he alleges GPs are providing, especially through restrictive telephone booking systems. He has told practices to do better if they want more money.
Most GPs consider this criticism outrageous. They say they have stuck with these systems, often introduced during the pandemic, to cope with workloads that have become unmanageable.
Whether or not the criticism is fair, it is cunning politics. Nesbitt has zeroed in on a problem that aggrieves the public. When the BMA warns its action will mean fewer appointments and a worse service, many people roll their eyes and ask how anyone will notice.
The minister’s tactics are remarkably aggressive, a fact that deserves more recognition, even from those who agree with them. The conventional approach to any pay or funding dispute at Stormont is to tiptoe around every interest group involved while bemoaning a lack of resources.
GPs are the archetypal middle-class professionals and Nesbitt is cut from the same cloth, which may explain why he is acting like a man who has the exact measure of his opponents. If he faces down the BMA he will have demonstrated a flash of steel neither he nor Stormont were known to have possessed. But if Nesbitt has overplayed his hand and more practices start exploring their private options, this could be the beginning of the end for free universal primary healthcare in Northern Ireland.
