‘Copperfield has it dead wrong about the dentist model for general practice’

Dr Tom Black argues that recruitment pressures in Northern Ireland and lessons from the Republic of Ireland mean a hybrid model of general practice may be unavoidable

Copperfield got right up my nose with his recent blog ‘Dentist model lacks bite’ about the BMA’s announcement that it will ballot GPs in England with a ‘Plan B’ or hybrid model of general practice.

I write to you from Derry in Northern Ireland, UK – just 400 metres from the border with the Republic of Ireland. Here, we cannot get GP locums or partners because they all work across the border for ‘double the money, half the work’. This has already led to discussions at LMC level about developing a ‘Plan B’ for general practice, as concern over the current model continues to grow.

The recruitment crisis here is now dire because we cannot compete with Sláintecare – the Republic’s major programme of investment in healthcare. Where I’m practising in the west of Northern Ireland, I’ve seen the impact first-hand, with an 18% drop in practice numbers in the last decade.

Half the patients in the Republic of Ireland have free healthcare – like the NHS. 46% of patients then take out private cover and pay about €50 per GP consultation. These patients sit in the same queue at the same local GP practice. It isn’t too dissimilar to the free school meals scheme – where some children pay and others don’t but, in the end, receive the same dinner. 

The mixed model also makes general practice a more attractive career. GPs in the Republic earn more and, from what I have heard, patients often have a greater appreciation of the service because they understand its value and cost. An average practice with a hybrid model can earn €30-40k per month extra on top of state funding, while GP partners may earn €200,000-€250,000 a year. This reflects the wider funding model in place.

Because a substantial proportion of patients in the Republic of Ireland contribute directly to the cost of many GP consultations, this may encourage greater self-management and more selective use of primary care services. Recent OECD figures show that life expectancy there is almost two years higher than in the UK, and the WHO shows that there is also a marked difference between Ireland and the UK’s healthy life expectancy.

I cannot solely attribute these outcomes to the result of Ireland’s mixed model. But at the very least it does show that a public-private system can achieve outcomes that outperform those in the UK right now. And so, from where I am standing, hybrid general practice works and is better for both GPs and patients.

In comparison, the NHS is underfunded, understaffed and overwhelmed. Politicians are only interested in providing a ‘pretend GP service’ – one where an AI avatar takes the call, the patient is seen by an HCA or another member of the MDT, and there is a GP somewhere in the background taking responsibility but whom the patient never actually sees. Without an alternative vision from the profession, that model risks becoming the default.

Deprived and vulnerable patients will suffer as a consequence. Those who can afford to will go to separate GP services outside the NHS – probably run by multinationals, much as has happened in the veterinary sector where ownership has increasingly been consolidated by large corporate providers rather than practices remaining owned and run by vets themselves.

‘Invest more funding’ has been the BMA mantra for a generation but my own 30 years as a BMA leader tells me that this isn’t going to happen. Ever. To persist with that strategy is naive, lazy and hypocritical. More crucially it will fail the profession by undermining the autonomy and flexibility that come with the independent contractor status, leaving GPs with ever less say over how care is organised and delivered, while betraying our most vulnerable patients. 

The NHS undoubtedly needs more funding, but asking half the population to take out private health insurance to contribute towards their healthcare costs is a form of progressive taxation. Keeping the NHS intact while securing this additional funding stream could prevent a two-tier service from emerging.

English GPs have a phenomenal leader in Katie Bramall, but AI is about to eat GPs’ breakfast; and MDTs will eat our lunch; so, if you want to save your dinner you need to vote for a Plan B/ hybrid model of practice. Better to be part of shaping some sort of solution than to have a third-party model imposed upon you with no say whatsoever. Some might liken it to sitting on your hands and boiling like a frog.

Dr Tom Black is a GP partner in Derry, Northern Ireland, former chair of BMA Northern Ireland, and former chair of BMA Northern Ireland’s GP Committee