£100,000-a-year GPs threaten to cut services as they're refused a pay rise

They say they face financial difficulties, despite lucrative new contracts paying them an average of £100,000.

The British Medical Association has circulated guidelines for what amounts to a work to rule, a favourite weapon of public service unions in the 1970s and 1980s.

The move met incredulity from patients' groups, who accused GPs of wanting more for doing less.

Under a deal introduced in 2004, GPs were able to opt out of out-of-hours cover – taking a small pay cut for doing so – while earning more money for extra services such as checking blood pressure and weight.

The changes saw their pay soar by some around 30 per cent for working fewer hours.

Last month, after accusations that the Government badly misjudged the deal, Chancellor Gordon Brown decided not to increase payment rates this year.

Now the BMA, which decided not to ballot on industrial action, is telling GPs which services they can cut without breaking legally-binding contracts.

The BMA said they might want to "consider whether to take on new patients", as well as reviewing "enhanced services" like minor surgery, including ingrowing toenails and the removal of warts and suspicious moles.

"Enhanced services" also cover the target which says patients should be able to able to book an appointment within 48 hours.

The hardline attitude could threaten the government's aim of moving more care from hospitals into the community.

Dr Hamish Meldrum, chairman of the BMA's GP committee, said: "For the second year running, GP practices will have no cost of living increase in resources while facing the rising costs of running an NHS practice, paying the staff, the utility bills and all the other expenses.

"The decision to give GPs no extra funding at all – in effect a cut – will put practices all over the UK under considerable financial pressure."

Dr Meldrum added: "I believe GPs care deeply about their patients and staff.

"But they also care about being treated so badly after they pulled out all the stops to deliver a top-quality service under the agreed terms of the new contract."

Victoria Bourne from the Patients Association said the public would not be impressed.

She said: "GPs admit they are getting more money for doing less so wepatients who suffer when the unions and the government are at loggerheads. This will hit vulnerable patients disproportionately.

"GPs must reassure patients they will receive the service they are paying for and which they thought would be provided under the new contract."

David Stout of the NHS Confederation, which represents trusts, called the BMA's advice "shocking".

He said: "It is disappointing that the GP committee is threatening to impact on patient care and derail the NHS improvement programme.

"We hope and expect that the majority of GPs won't follow the advice.

"GP practices are small businesses. In every other walk of life, we would expect small businesses to look at new ways of improving their services and seeking efficiency savings. GPs should be no exception."

Blair Gibbs, campaigns director at the Taxpayers' Alliance, said: "GPs are being very greedy. They have done very well for themselves.

"This is what happens in a socialised healthcare system. Whatever gains they get is our loss. GPs have got taxpayers over a barrel because the Government has given in to their demands."

But Tory health spokesman Andrew Lansley said: "It is appalling, given Labour's doubling of health spending, that GP surgeries will now follow hospitals in having to make cuts.

"Like everyone else in the NHS, GPs are realising the extent of the famine that follows the feast. Even more patients will now see at first hand the effects of the financial crisis in our NHS."

Liberal Democrat spokesman Norman Lamb said: "There are a lot of angry GPs out there who are now unwilling to carry through the government's reform agenda for the NHS.

"This cost-cutting nightmare is a worrying sign of things to come when funding across the NHS is reduced from next year."

A Health Department spokesman said: "The BMA's advice is based on no economic rationale and would actually hit GPs' pockets.

"We are surprised they feel the need to issue this advice, when GPs have had a 50 per cent increase in recent years."