‘If I opened my list to new patients I would have to report myself to the GMC’

Pulse’s latest investigation revealed new data on the number of practices applying to close their patient list – a last throw of the dice before handing back their contract. Here, BMA Northern Ireland chair and GP partner Dr Tom Black explains how he took ‘informal’ measures after having his application rejected.

We have closed our list, based on the fact that we have close to 2,500 patients per whole-time-equivalent GP. That’s a very big ratio of patients to GPs. And particularly so given that my practice in the Bogside, in Derry, is in an area of high deprivation, and it’s my job to look after those 7,000 patients.

We have the longest waiting lists in the known universe in this area, so my patients would be waiting five or six years for anything outpatients and inpatients. So if you need a hip replacement you’ll wait 10 years probably. In other words, you’ll never get your hip replacement because you’ll die. That’s the type of pressure that we’re under.

We put in a list closure application in February this year. We eventually received a reply more than six months later saying that our application had been declined. That would be the view of the Strategic Planning and Performance Group (SPPG), and the Department of Health (DoH). But clearly, they should only make that decision if they follow the regulations and guidance, which they failed to do.

The regulations say you should reply within 28 days, not six months. You should make all evidence that has to be considered available to the applicant, and have a meeting to discuss said evidence. So on those two points alone, the regulations were not followed. I’m not a lawyer, but it seems logical that you can only turn down an application if you actually follow the regulations.

So I replied and said: ‘I’m sorry, but what you’re asking me to do would be in breach of Good Medical Practice’. Because Good Medical Practice (GMP), the newest edition from the General Medical Council, which will take effect in January of 2024, is very clear on what to do in circumstances where there are limited resources. And my interpretation of GMP would be that I should not take on more patients when I’m struggling to cope with the number of patients I have. So, in other words, if I opened my list and took on new patients, I would have to report myself to the General Medical Council. That’s something I’d rather not do.

I’m an independent contractor. I contract with the board. I expect them to apply the regulations. If they fail to, I will. The regulations are very clear. I can’t open my list. The General Medical Council is very clear. I can’t open my list. I’d rather not be in breach of my professional responsibilities. So my list is closed.

My doctors are seeing 35 to 40 patients a day. It’s really, really busy, mainly because there’s been about a 30% increase in workload due to our long hospital waiting lists. So you can’t expect us to cope with these long waiting lists, and keep taking on more and more patients.

We lost a partner, a resignation from the practice. And we’ve also got notice of another doctor who’s due to leave the practice next year. It leaves us in a very difficult position. These are things that you go through, and I’m not looking for sympathy from anyone. But I’m certainly not looking for extra work either, by taking on more patients.

I’m not closing my practice. I’m not handing back the contract. We will stay and we will do our very best to provide the service. But the service is already compromised because of the workload.

Can you imagine if I was up before the General Medical Council for failing to do a house call, let’s say, and they said ‘but you have far too many patients, and not only have you far too many patients for whole-time-equivalent, but you kept taking on more patients to make more money’. Could you imagine them saying that to me? But I would say ‘oh no, I didn’t want more money, I wasn’t trying to take on more patients, I was forced to’. They’ll say ‘no, you’ve a professional responsibility to maintain the values within Good Medical Practice’. They would have no sympathy for me at all if I fail to look after my patients correctly. To some extent you are between a rock and a hard place.

There are other practices in Northern Ireland who have applied for list closure and been declined. My concern is that the only practices who seem to be allowed to have a list closure are those practices which have already handed back their contracts. Now, that seems to me an extraordinary state of affairs. So you actually have to hand your contract back to the Department of Health, for them to allow you to close your list. That seems not just counter intuitive, but a bit unreasonable. So in other words, it seems to be that you have to be their problem for them to allow a list closure.

I formally closed my list about five or six years ago. And at that time, I had far fewer patients per whole time equivalent. In other words, my list has been closed before with a lower ratio than I have at the moment. So custom and practice has not been followed, regulations haven’t been followed, guidance hasn’t been followed. This all seems very unreasonable.