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Northern Ireland GPs’ open letter to health minister Robin Swann

We are a group of concerned GPs who are taking this unprecedented action to protect the interests of our patients and address the concerns we are facing during these difficult times.

When it became clear that a major crisis was emerging which threatened to overwhelm the NHS, there was never any doubt that general practitioners would be at the forefront of measures needed to manage this pandemic. We recognise that urgent and immediate actions were necessary and that full consultation with all likely participants would have been difficult in the initial stages of this process.

Despite many GPs expressing reservations and concerns regarding the establishment of Covid centres and the methods by which it was proposed they would operate, the vast majority of GPs participated in this initiative recognising the threat the pandemic posed for the NHS.

It is now clear, that the peak of infection has passed and fortunately the worst-case scenario did not occur. We have reflected on measures taken and now believe it is the time for proper critical analysis.

Our primary concern is to ensure as rapid a return to normality as possible, cognisant of the continuing threat from Covid 19, but knowing that further major issues are rapidly looming for general practice and our patients.

It has been well documented that during the peak of infection patients with other symptoms and concerns were not presenting to primary care services or emergency departments, despite efforts to encourage patients that capacity to address these was still available. Naturally there has been a reluctance of patients to present with these problems mainly due to concerns of contracting the virus.

Nonetheless, primary and secondary care services have recognised that the delay in patients presenting with these symptoms must be addressed and in many cases as a matter of urgency.

A perfect example of this was highlighted in the Irish News on 3 June this year where a retired nurse found it impossible to access NHS services, despite a ‘red flag referral’ done in January 2020 and indeed she found it very difficult to access any help even through the private sector.

We know that there are many more such examples across Northern Ireland. There have been worrying delays in patients’ access to further investigations, diagnostic procedures and there have been delays in chemo and radiotherapy. Waiting lists were already the worst in Europe and it is imperative that measures are now taken to address these matters.

Despite extremely limited demand, Covid centres continue to operate across the country. GPs are still expected to fulfil rotas while workload is rapidly increasing in their own surgeries.

Participation in Covid centre rotas is not voluntary, despite statements in the media and as evidenced by the letter sent to non-participating practices by Mr Richard Pengelly (Permanent Secretary).

We are repeatedly told that Covid centres need to continue to ensure practices are kept clean of Covid infection, despite the reality that most infections are transmitted in the pre-symptomatic phase or by asymptomatic patients.

Given that patients with no symptoms of Covid infection could still have other symptoms or signs of serious illness that must be addressed, the raison d’etre for Covid Centres no longer exists.

We have scrutinised available data to assess the demand on Covid centres, the costs of operating these and the potential benefits they provide.

Unfortunately, any information we have been able to acquire indicates many GPs working in Covid centres are seeing few if any patients and our analysis demonstrates that for every patient seen, the minimum cost to the NHS is at least £1000.

The Department of Health has acknowledged expenditure of £1,538,400 on June 2 and we believe this figure to be a considerable underestimate given that GP payments had not been processed by that date.

Grandiose proclamations that Covid centres have kept patients out of hospital are devoid of reality. Either patients needed hospital admission, or they did not.

At best, there may have been a reduction in the number of patients attending hospital for assessment, but it is clear now that emergency departments were not overwhelmed during the peak of infections.

There have been many recorded instances where no patients have attended some Covid centre shifts or there have been a 2 to 1 doctor patient ratio during some shifts.

In fact, it has become clear that most of the work conducted by Covid centres could have been conducted by appropriately trained nurses. The unavailability of swab testing, access to x-rays and blood tests further limits the usefulness of Covid centres.

Many practices have not sent a single patient to a Covid centre in the entire time of their existence. Our evidence also indicates that currently many of the referrals to Covid centres are entirely inappropriate.

We understand that arising from the crisis, new proposals for the way forward are being considered. Who is involved in these discussions is as yet unclear but given the manner in which decisions were imposed on GPs at the outset of this pandemic, we are seriously concerned that similar changes to the way we have traditionally operated could be further imposed.

This will not be acceptable to vast majority of GPs and goodwill has already been significantly eroded. The fact that Federations, supposedly led by GPs for GPs, were utilised without the consent of their membership has significantly undermined their credibility as organisations representing our best interests.

In our view, the British Medical Association and Royal College of General Practitioners have also failed in this regard. The fundamental strength of General Practice has always been ‘independent contractor status’. We can decide what is best for our patients and act in their best interests. Knowing our patients has been the bedrock for the services provided to them by the NHS. This must not change.

The reality of today’s NHS is that general practice is the only element that is functioning to any degree, such that this can still be called ‘a service’. Unilateral attempts to impose, tinker or transform general practice threaten to undermine one of the few aspects of the NHS that generally serves patients well.

Already we have seen significant developments which are detrimental to general practice. Ineffective planning has failed to recognise that more GPs needed to be trained, exemplified by the loss of many practices in rural areas. Comparatively general practice is significantly underfunded compared to the other nations within the UK.

There is no scope to expand the role of the GP further without consultation and without requesting their cooperation.

Federations being instructed to organise rotas may have fatally undermined their continuing existence. Morale within general practice is at an all-time low and time-off has proved virtually impossible to arrange. We need to get back to managing our patients and addressing their concerns as only we know how. Let us get on with our job and get back to our patients.

This has been signed by 130 GPs in Northern Ireland