How bad is Northern Ireland’s general practice crisis?

In an exclusive interview, the BMA Northern Ireland’s GP Committee chair Dr Alan Stout discusses the country’s pressing issues, including its lack of political leadership.

The BMA NI recently published its ‘plan to save general practice’ which summarises the policies it has been repeatedly calling for.

Political situation and workforce issues

Q: How does the current political situation in Northern Ireland impact on general practice?

A: Importantly, to start with, the work that we’ve been doing isn’t even dependent on the political situation being resolved – it’s too important and it’s too urgent for that.

So this [plan to save general practice] is for when we’re engaging with our politicians. But this needs the Department of Health to act, and we simply can’t wait any more for the assembly, for the executive, to come back. We’re not hearing anything imminent, that they’re going to return.

What we’re seeing is not only the service really struggling – partly because of a lack of political leadership, partly because of the lack of any proper budget, particularly a multi-year budget – we’re actually seeing our services going backwards now at a rate of knots. We’re obviously seeing the day to day crisis, but our biggest fear is that we’re actually getting to an irrecoverable position. We’re not even looking at next year, thinking we could resolve this for next year, we’re thinking even over the next three, four, five years it’s not going to be recoverable.

The biggest factor in that is workforce alone. You can obviously start to then talk about the funding and the resource and everything else. But the workforce is what is terrifying us at the moment. In general practice – this is right across the health service in Northern Ireland, just about every area that we look at – but in general practice alone we just are not training enough people to replace those that we’re losing. We are not retaining people either. And that is a huge fear that we’re just not going to have the workforce to deal with it.’

Q: The Northern Ireland Department of Health confirmed last month that there is no funding to implement a 6% uplift to NHS staff including GPs, which was recommended by the DDRB for Northern Ireland, Scotland and Wales. What impact is this having?

A: Full credit for Scotland, who have moved above and beyond what the DDRB actually recommended and have recognised the need to do that. In Northern Ireland, we’re sitting at 0%. So we have a workforce – with no imminent uplift at all – who, if they look left, they look at what Scotland are doing, and the enhanced rates and the pay and the conditions Scotland are offering, and all they need to do is look right and we’ve got Sláintecare in the Republic of Ireland, which is very actively targeting increased workforce and offering really good terms and conditions and really good pay, and we will lose our workforce either way.

We already see that – the evidence of that is in our training numbers. So we fought very hard to keep our training numbers at 121, but we’ve only filled 99 of those 121 places. And of the people filling the places, 60% of them don’t originate from Northern Ireland. It’s a mobile doctor population, by very definition, before we even start. And if we don’t get the retention, if we don’t get the terms and conditions, which includes pay, right, people are leaving, and we just won’t have anybody here to deliver service.

Q: Is the lack of a 6% uplift having an impact on retention of GP practice staff?

A: Absolutely, you’ve got a job that’s just getting harder and harder and harder. You have a workforce that feel that they’re just not being valued. Also, it has the resulting very obvious impact on morale. People quite naturally look elsewhere, and look at other careers and other parts of workforce, and they will move. We’ve talked for years and years about this ‘learned helplessness’ within the health environment, but we now have a ‘forced helplessness’ where we have poor pay, poor conditions, huge pressures, and an inability for anybody to do anything about it.

One kind of positive message in the midst of it all is that there was a letter from the permanent secretary saying that he wanted to recommend [the 6% uplift], or that he would be recommending it, but that it would be subject to funding. So that at least suggests that there’s going to be a recommendation to any incoming minister. But, again, when’s that going to be?

Before the assembly collapsed, we had this tantalising glimpse of a multi-year budget, which is so important for forward planning and things like pay uplifts and so on. But that’s all just gone out the window as well.

The BMA’s plan to save general practice

Q: What’s your number one priority to ‘save general practice’ in Northern Ireland?

A: Number one is definitely indemnity – it now just sticks out like a sore thumb to absolutely everybody in Northern Ireland. GPs in Northern Ireland are the only healthcare professionals in the entire UK that are paying these astronomical sums for personal indemnity. And it is effectively a tax to be a GP in Northern Ireland.

And because of the inaction from when England and Wales solved it, when they moved into state-backed indemnity, it has taken on a disproportionate importance to every GP in Northern Ireland. They now see it simply as a barometer of, you know, does anybody actually listen or does anybody actually care?

Q: What does this mean for the risks facing GPs?

A: With the wider health environment struggling so much, with the waiting lists and our emergency departments and the pressures there, what actually happens is that patients just keep recycling into general practice.

It is just such an obvious omission and gap in Northern Ireland, but also with the increased risks in general practice from patients recycling, from waiting lists, and from EDs under pressure, pressure to discharge patients earlier and earlier, the risks are going up substantially. But yet, we’re being expected to pay handsomely to cover off those risks.

Q: What has the Government said about the future of GP indemnity?

A: We hear little positive from them. There is a paper on it somewhere, allegedly, which we haven’t seen. And they say that they’re having internal discussions and need some sort of proof or evidence of the value for money of doing things like that.

Q: Your plan to save general practice says you want to see QOF move ‘into core general practice funding’. Do you want it to be abolished?

A: In a nutshell, yes. What we hear from patients, from politicians and actually from the Department of Health themselves, is that people just want access and they want our GPs and our practices to focus on being as accessible as possible. So the more distractions there are to access and the more funding that we have to chase through targets or enhanced services, the worse access will become. I’m not sure I’ve ever met anybody who disagrees that access is of the most fundamental importance in general practice for somebody who’s sick or perceives themselves to be sick. If we know that that is the priority, that’s where we need to prioritise the funding and hence the activity, and just remove the bureaucracy, remove the target driven culture and simplify it.

So that’s one part of it, just simplifying that funding model, but on top of that we also need to make sure that we’re paying for the service that we already have. We know we have 70,000 unpaid for patients in Northern Ireland which equates to 11 practices effectively. We need to make sure that we’ve actually got the right level of funding for the population that we have at the moment. But then further to that, we then need to increase that further. Because when we talk about healthcare reform, whether it be in Northern Ireland or anywhere else, primary care, general practice as part of primary care, has to be a fundamental foundation to that. And hence you need the resource, and you need the staff there to be able to deal with it.

Q: How likely is it that the Northern Ireland Government would endorse the BMA’s safe working guideline of 25 patient contacts per day?

A: I doubt they would, because they will realise pretty quickly that general practice is unaffordable. But the concept, which we now have to take on and we have to be giving advice to our colleagues on, is that we cannot be asking our practices and our GPs to take full responsibility for actions that aren’t being taken elsewhere, in terms of compromising safety, and quality, and their own well being. Because we hear horror stories of what GPs and what practices are going through every day. We cannot be the only ones that are actually taking action or taking the responsibility for that, simply by seeing more and more and more. So it is a failure of policy, it is the failure of funding, it is a failure of workforce that is creating these pressure points. And we have to keep our GPs and our colleagues safe in such a difficult environment.

Q: You have also urged progress on the roll out multidisciplinary teams across Northern Ireland – why has this stalled?

A: Funding, priorities as well. So it’s a seven year old plan, and to date, we only have one fully-fledged MDT in our in our federation areas. We’ve got a few partial MDTs, but we are nowhere near, seven years down the line, getting that across all practices.

[We’re aiming for] an MDT that is linked into every practice. They’re federation-based, but very much linking in with every single practice in that federation.

Q: Your plan highlights the need to return work to trusts in order to stop workload dump. But how feasible is this given the massive challenges facing secondary care?

A: I don’t think it even needs to be as complicated as that, it’s just about doing simple things well. So if a patient is on a waiting list, they don’t need to contact their GP to check – and we can’t even tell where they are on the waiting list. There should be a contact within the trust, where the patient has been referred to, that can deal with that. So that in itself would solve an awful lot of contacts with GP.

But it’s also just simply doing the right things and in the right place. So if a patient, for example, is being discharged from hospital, or is at an outpatient clinic, and somebody is telling them that they need to take a couple of weeks off work – just give them a sick line there and then, don’t tell them to go to their GP to get a sick line.

Just give them the medication, don’t tell them to come to their GP to get it. So, you know, it’s just doing those simple things, which can be done at the moment. It’s not changing any contracts or changing any rules or regulations. It’s just doing those simple things.

Industrial action and levers for change

Q: Given all these issues facing general practice, is industrial action on the horizon for GPs in Northern Ireland?

A: Industrial action is trickier as independent contractors. We’re not salaried, so there are lots of quirks within that.

The second point is industrial action in Northern Ireland is even more difficult, because we don’t have a government that can actually step in and act and resolve it. We don’t want to take industrial action that is potentially harmful to people without having an obvious way of resolving it.

And then the third point is that with 16 contract hand-backs, we’re seeing it play out in front of us without actually going to take industrial action, because we’re seeing people then just taking their own action.

What we have, which complements this plan to save general practice, is we also have an options paper, which is a dynamic paper. And what we’ve heard loud and clear from our representatives is that they want to solve the problems that general practice has within the current environment, within the contract with the NHS. But one of the options is to simply leave the current contract and come up with an alternative option. And we’re hearing that more and more and more. If we cannot see action on these fundamental things that need to be done, that’s where the profession is going to drive us to.

We’re basically doing everything we can to avoid going or being forced to go to that option. And we’ll be forced from the grassroots to go for that option.

Q: What lobbying mechanisms does the BMA actually have within the current political environment?

A: So in the current environment, the decision makers are civil servants. So we have lots and lots of meetings with them. But it’s so important that we start to see some sort of outcomes and some sort of action from all of those meetings.

But we’re also constantly engaging with the political parties, and particularly with their health leads, in the anticipation that at some point we’re going to get an executive back, and if we do, we need to really hit the ground running with that and be prepared. We’ve met with four of the five political parties even over the past week, we’ve got the fifth one imminently. It’s really keeping them informed and up to speed. And actually, in fairness, they have been very supportive, they’ve been very understanding, and they’re very well up to speed with all of the problems. The vast majority of them are just as frustrated as we are with current situation.