In a series of articles on the state of general practice in the devolved nations, Katherine Price explores the growing instability of practices in Northern Ireland
Northern Ireland has seen a domino effect of practice closures over the last year, with 13 contracts handed back over just a 12-month period.
There were 318 GP practices in Northern Ireland at the end of 2022, one less than the year before – and down from 336 in December 2018. Worryingly, around 30 of these are also at risk of closure and receiving recovery support from the Government’s Practice Improvement and Crisis Response team.
Most notably, in February, a practice with 7,600 patients handed back its contract, making it the third in County Fermanagh (pictured) since last summer – which Pulse highlighted as being a particularly badly hit area in 2018, along with Portadown.
Council chair for RCGP Northern Ireland Dr Ursula Mason says the situation ‘speaks volumes’ about the state of general practice in the country.
‘If you can’t recruit into a GP practice and sufficiently have a workforce that provides care then you have to make that really awful decision to hand back your contract, because you can’t continue to provide a safe and quality service,’ she says.
‘The real challenge is that GPs really do know that there’s a massive impact on their patients when they have to take that decision…[but] for many each day when they go to work, they’re working at full capacity, they’re working longer hours than they can in terms of their ability to give to the job that they do, and we’re seeing increasing numbers of GPs here burnt out. It just can’t continue.’
Among the reasons cited for closures are difficulties attracting new doctors, poor infrastructure, and a lack of investment, centralised support, and planning. GP leaders have previously said that the problems are ‘particularly acute’ in the West of Northern Ireland where it is ‘even harder to recruit GPs’ and ‘the risks to other practices of a list dispersal are even more destabilising’.
The role of the Department of Health’s crisis team is to try and support practices with locums or multidisciplinary teams as far as possible to prevent collapse – but with locums in short supply this remains a challenge. And in some cases, stakeholders have been unable to find replacement partners to take over crisis-hit practices, meaning they are taken on by local trusts.
GPC Northern Ireland chair Dr Alan Stout says the biggest challenge for general practice in the country is ‘by far’ stabilising practices. He tells Pulse: ‘…That is not only in terms of what’s being expected of them and the sheer volume of workload, but also financially, because of the huge financial hits that they’re taking with the various costs increasing substantially. That’s very much short-term – long-term we need workforce and indemnity solutions.’
However, the political situation in Northern Ireland is hampering progress. The country has been without a first or deputy first minister for over a year, the Executive Committee has not met and civil servants cannot make any ‘political’ decisions, only follow policies previously set by ministers. Dr Stout says GPC still have the ability to negotiate with the Department of Health in the absence of ministers and look for ‘various mitigations’, but ‘even their hands are tied’.
‘They are doing their best and they recognise the problems, pressures and issues, but even their hands are very tied at the moment and the biggest issue is just the lack of any meaningful budget, but also particularly any recurrent budget,’ he explains.
‘So even though they know, and they can appreciate the various funding [that needs to be] covered off, there’s no mechanism or money or ability to do it.’
He adds: ‘The baseline is firefighting at the moment. It’s definitely not planning and funding for the future, it’s simply firefighting and trying to cover off problems as they arise.’
The lack of investment in general practice is a major problem though, as GPs buckle under increased demand. GP leaders report ‘increasing asks’ on dumping workload from secondary care into primary care, but without the resource to meet it. And Government statistics show the average number of registered patients per practice has increased by around 9% since the end of 2017.
As Dr Mason concludes: ‘With the difficulties around recruitment, retention, workload, workforce, we have seen a significant increase in the number of GP contracts being handed back through the Department of Health, because there is simply not enough resource in those communities to continue to provide that service.
‘That has a significant impact on patient care, but also has the potential to destabilise other practices, and there’s a real risk in certain areas of total collapse if these practices can’t be saved.’