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Pulse Q&A with Northern Ireland health minister: ‘GP model not offering work-life balance’

Pulse Q&A with Northern Ireland health minister: ‘GP model not offering work-life balance’

In our interview with health minister Robin Swann, Caitlin Tilley learns there is ‘less antagonism’ between GPs and other doctors in Northern Ireland

There have been a lot of practice closures in areas of Northern Ireland such as Fermanagh. What were the issues in this area and how are these being dealt with?

We have seen the number of GP practices in Northern Ireland decrease in recent years, with 353 in 2012, down to 321 now as of April last year – a 9% reduction in the number of practices over that period. So we’ve had to be agile to look at different ways to minimise disruption to patients where the Health and Social Care board does receive those notifications of potential closures, and we then take all the necessary steps to secure the continuation of GP services.

Or, we look for the additional support from our GP federations. And they have played a key role in supporting the resilience for GP practices, and that provides the opportunity for pooling of resources, but also enhancing the skill mix to increase the range and quality of services offered by GPs at that local local level as well.

But part of the challenge that we’re now seeing is the change in age and the demographic of our workforce. And also the GPs [are] now looking for a work-life balance, which the current models and the current working practices that they’re under isn’t offering them.

I still think it is an attractive profession, but people are looking at it differently now as well. And we were looking at a number of practices where they were either family-run [or] family-based and those who’ve been looking for someone to continue on that practice.

And it’s about the skill set, but with many dedicated GPs, many dedicated professionals, coming through looking at GP practices from the health and the support services they can provide to a local community.

What people often forget is that a GP practice also comes with the management of a business as well. So it’s that skill set, that skill mix, where we now see GPs wanting to be health professionals, and the additional responsibilities and challenges that come in with managing a business is something that we haven’t seen as many of them coming forward with.

We’re looking now at the Federations that we have here in Northern Ireland, and what more can be done in regards to getting that skill mix into the practices.

Is it happening in any other areas in Northern Ireland? Why is it happening?

We’re reshaping our primary care services and we’re rolling out our multidisciplinary teams (MDTs), and they’ll be delivering new capacities and innovations into our primary care and bringing services closer.

I believe it’ll bring those services closer to the communities, improving access to our citizens, but also taking pressure off our GPs as well, so that people are seeing the right healthcare professional at the right time, for the right treatment and support.

In your elective care framework you said: ‘An increase in GP numbers will be necessary to maintain existing primary care services and support the expansion of elective demand’. Have you looked at exactly how many more GPs will you need to get through the elective care backlog?

I suppose one of the things that the Covid pandemic has really shown us here in Northern Ireland is the closer working relationships between primary and secondary care.

So when we looked at the elective care framework that we published in June last year, about how we start to get on top of our waiting lists, GPs played a key role in that.

But their biggest challenge again, like many sectors of our health services, is workforce. And [in] June 2015, we published a general practitioner workforce planning group. They produced a final report that recommended, at that point, we needed an increase in the number of commissioned GP training places. At that point [in] 2015, [it was] roughly 65. And that has increased now to 111. It came in August 2019, this was [a] 71% increase in the number of students coming through that GP report so we have increased the numbers over that range.

But again, I’ve established a task and finish group within my department working with our Health and Social Care board and our Northern Ireland Medical & Dental Training Agency, and I’ve asked that task and finish group to determine the need and the quantum for additional GP training posts over the next five years. So not solely to look at the additionality of the elective care framework, but also to support the increasing number of GPs that we need to balance that out, to make sure there is a supply chain to counter those who are retiring and leaving practice.

It’s due shortly, I hope to get it in the next couple of months. But one of the things that we’ve done as well, I suppose it was a big step for Northern Ireland, we’ve opened a graduate entry medical school at McGee University up in Ulster University up in the northwest and we enrolled 70 students there. And the curriculum of that programme places a high emphasis on primary care placements. A significant concentration of those clinical placements will be in rural settings and the west or northwest of Northern Ireland.

What are the barriers to general practice workforce in Northern Ireland, and how will you overcome them?

Part of the problem is we’re playing catch up on workforce. A number of my predecessors cut training places, cut our health workforce to a point that we are now paying the price of that under investment, not just in the buildings or equipment that we have, but also workforce. So if we’d have continued the pipeline of GPs coming through the entirety of the workforce over the last 10 years, we wouldn’t be [at] the current point we’re at now, where we are seeing that our current workforce [is] over 50s, because we would have more students coming in behind them.

And that’s why the increase in training numbers over the past two to three years has been critical and we are doing that assessment to see how many more we need. Because we know our health service works as one unit. If you put pressure on one place, it’s felt elsewhere and across the entirety of the system. And that’s why we’re seeing the additional pressures coming on our GPs.

I think one of the unfortunate things is we’re also seeing a narrative over here now being pursued by some of our politicians, and some sections of our media. And I think it’s been unfair to our GP workforce and the narrative [that] they’re not open, they’re not serving their people, they’re not looking after the constituencies that they’re working for. And I think that narrative is unhelpful in the perception, but also on the GPs themselves, because it’s putting an additional strain and stress on them that I think is unfair.

Like elsewhere across the UK, our GPs are contractors, they hold contracts with our health and social care board. So when it comes to additional incentives for additional work and supports, the main piece of work that we’re doing, and supporting our GP professionals, is that we’ve put additional monies into GP practices towards the end of last year, but it’s also the promotion of our MDTs, of how we enhance the service that our GP practices are providing and then by doing that, ease the workload off them as well, where they actually get to see the patients that they need to be seeing, where there was other professionals that are part of the multidisciplinary team [that] are seeing the patients that they need to be seeing as well.

There’s been lots of calls for the MDT rollout to be completed in Northern Ireland. In our Building a Better General Practice survey, GPs were in favour of MDTs with GPs heading them up. Why is it not being fully rolled out in GP practices yet?

There was always scheduling in MDTs about a phased approach. Currently, I think our MDTs cover over 600,000 citizens in Northern Ireland, so roughly a third of the population are covered by an MDT. And over 300 whole-time equivalents of frontline staff working across those GP practices that are part of a multidisciplinary team programme.

The significant challenges that are faced by primary care colleagues, where we don’t have MDTs or complete MDTs, are either to begin and then to just complete the rollout of MDTs.

The challenges that we have come down to a continuation and a commitment to funding our department here and we’ve been working on a one year non-recurring budget. Now starting from this year, we’ve got certainty that it will be a three-year budget, but the finalisation of the quantum hasn’t finished. So we rely on that certainty to get the rest of the MDTs rolled out.

But it’s also to be noted about the professionals that we need, because there’s no point in creating a system that simply takes health professionals from one part to put it under pressure, to put them into somewhere else as well. So the composition of our MDT models was designed in regards with stakeholders across our health and social care system, our GP federations and the third sector as well.

And that was informed by the analysis of the demand that it needs. So, it’s about making sure we can get secure funding for them, but also that the staff we’re bringing in aren’t being moved from somewhere else that simply puts pressure elsewhere, and depletes our service somewhere else.

Would an MDT model work for out-of-hours GP services?

We are looking at our ‘No More Silos’, which was work that was commenced pre-Covid, in regards to how we need to professionalise and streamline our out-of-hours services.

There’s a major piece of work going on there in regards to what the future of that looks like, because we do need to make sure there’s a consistency of service across Northern Ireland and there’s no differential, depending on where you live, about what the out-of-hours service actually looks like.

Are there any plans for GP practices to be run by hospital trusts in Northern Ireland? Why/why not?

We don’t have any intention of going down that route at this current time. The GMS contract that we currently have with our GPs is something that we’ll continue to look out and refresh as to how that can be enhanced, how it can be worked on.

But one of the things that Northern Ireland has, from the Department of Health, from the Health and Social Care Board, is a good working relationship and synergies across all our various sectors, so we don’t see some of the same differences of opinion or antagonism that can be seen elsewhere, because I have regular meetings with BMA, our GP committee, and our Northern Ireland GP committee as well, so those conversations go on on a regular basis so that we can have the conversations that we need to have about the delivery of service.

The Covid vaccination service has required huge effort from GPs – how will it work in the future?

It’s something that our GPs played an integral role in for our vaccination programme. One of the strengths that we saw coming out of Covid was that cross-sector working. Our GPs alone administered in the region of 1.4 million vaccines, over half a million booster doses as well. That was additional work to what they were doing, but it showed the strength that we had through direct GP involvement in administering those vaccinations.

That phase has now concluded. The normal vaccination programmes that continue and vaccination programmes for flu, will continue through our normal practices, should that be through GPs or community pharmacies as well. We also used our trust vaccination centres but we’re looking at scaling those back as well.

When it comes to the evergreen rolling programme, we are looking to our community pharmacy to pick that up. But should we need large scale booster programmes, we have a model now that works, that we can deploy quickly, that involves our trusts, our GPs and community pharmacies all mobilising very quickly. That model has worked for us just before Christmas very effectively, very efficiently. And we know that, if needed to be deployed at short notice, we can do it.

In November you announced a consultation on mandatory vaccination for new recruits, but there is still no date for the consultation. Is it still due to go ahead and what was the rationale behind it only being for new recruits?

The mandatory vaccination for health and social care staff is a significant issue – we believe it could only be undertaken after careful consideration. That’s why we went for the consultation and announced that last year both for Covid and flu vaccination for new recruits. The public consultation regarding those vaccinations for new recruits is under consideration.

The consultation hasn’t been progressed to publication and that’s just due to all our urgent priorities which my department is currently dealing with and as a result of the latest surge of the pandemic and that response.

I think we’ll also take into consideration the evolving situation that we’re now seeing in England, and determine the appropriateness of that consultation.

When we looked at where our current workforce was, the pressures on our workforce, it wasn’t something that we could bring in without public consultation. But [we] also [want to] look at where it would be best targeted as well. It was about the new recruits coming into our workforce, that we were giving them the appropriate supports that we felt were necessary.