The Northern Ireland GP crisis. The doctor won’t see you now…

Across Northern Ireland there is a shortage of 234 family doctors. Some 25% of GPs are over 55 so many will be retiring soon further worsening the situation.

The number of GP practices in Northern Ireland has shrunk to the lowest level in nearly a quarter of a century – and that each GP surgery in the region is, on average, now providing care to 500 more people than ten years ago.

Over the last decade, the number of registered patients has risen by 125,182 from 1.8m in 2004/05 to 1.92m in 2013/14 – an average increase per surgery from 4,948 to 5,474.

Yet the number of GP surgeries in Northern Ireland has fallen to just 351 – down from 366 in 2005 – and the lowest number since 1991.

GP’s act as the gatekeepers to the NHS, it is there job to make sure only the patients in genuine need get referred to hospitals. When people can’t get a GP appoint they are going to pitch up at their local A&E making the hospital crisis even worse. Some interesting stats from the Health Minister Jim Wells:

In 2008-09, 10·2 million consultations were undertaken by GP practices. In 2012-13, that had risen to 12·4 million, which works out as 6·9 consultations for every man, woman and child in Northern Ireland per year — almost seven consultations — which compares to the figure of 3·4 consultations per year in England. In the Republic of Ireland, it is only three.

There is a number of factors for the GP shortage:

Better jobs overseas: Jim Wells states ‘There are over 250 trained GPs from Queen’s University who are currently in Australia, Canada and other Commonwealth countries.’ Basically many GP’s are choosing to go for better paid jobs in the sun drenched shores of Australia rather than practice on a grim housing estate in NI. The pay is better, they are treated better, the hours are shorter – frankly who could blame them?

Most medical students are now female: this is a politically correct mine field but the facts speak for themselves. Over 60% of medical students are now female. Female GP’s tend to marry well (other doctors or professionals), they don’t really need the cash so when they marry or have kids many go part time or quit altogether.  They also retire earlier than male GP’s. 40% of female GP’s leave by the age of 40. To cut a long story short you need to train two female GP’s for every male GP. Before I get lynched by the woman folk of Slugger please read my family friendly recommendation at the bottom part of this post.

GP work is seen as a bit crap by medical students: it does not have the sexy life and death adrenalin rush of emergency medicine. It does not have the prestige of being a consultant or a surgeon. Medical students are the cream of the cream academically and frankly they see becoming a GP as just not that attractive.

Lack of coping skills: You are Clare. A top student from a nice middle class family. All your life you have had a charmed existence – been top of your class, captain of the netball team and debating society. You have friends that eat 5 fruit and veg a day, have nice shiny teeth and go on ski trips every year. Now you are in a tiny white room on a grim housing estate with Robert. Robert is 40 but looks 65. Robert wants your help because he can’t sleep or function due to being abused as child. Already Robert is on a string of antidepressants, anti-anxiety, sleeping tablets etc. You have 7 mins to help him. The endless stream of misery you hear on a daily basis starts to really grid you down. The helplessness of it all eats away at your soul.

Then there is the patients who calls you a f**king c*** because you can’t help him with his DLA. For good measure every now and again you get a patient on the verge of physical violence and you need to hit the panic button.

I am told around 50% of medical students who enter GP training drop out as they just can’t handle it. Dr George O’Neill takes the view that practising as a GP is now so emotionally draining that it will some be impossible for most of them to do it full-time, part-time will be the norm.

The bureaucracy: the government sure love their form filling. They also love their targets.

The long hours: as GP numbers decline the existing GP’s have a greater workload. This leads to a vicious cycle of even more GP’s going sod this and retiring, going part-time or going abroad.

The lack of actual medical work: most GP’s will tell you very few people present to them with real medical problems. Patients want help with their benefits. Other patients are lonely, sad or grief stricken, they have no one to turn to so they pitch up at their GP. In the old days they would just tell you to get a grip on yourself and get lost, but now a days every facet of human life has been medicalised and people expect a pill for all of life’s tragedies.

So what do we do about it?

Well here are some of my suggestions:

Increase student doctor numbers: offer students a free medical education. In return they must agree to work for at least 10 years as a GP. This could work by the health dept acting as a guarantor on a loan that covers all tuition costs. If the student does not fulfil their end of the bargain they get lumbered with repaying the loan.

Be more family friendly/group together: a GP locum gets £320-400 a day. Frankly if I got that I would only work 2 days a week too. Most GP’s will soon be female, we have no alternative but to make the job family friendly. If several GP’s band together into one health centre is easier to share the workload amongst them. Male GP’s are also feed up with the long hours and maybe would love a more flexible working arrangement.

Group together with other services into well-being hubs: Patients should be triaged when they come in to the surgery. You have a problem with your DLA? Talk to Mark over in our Citizens advice room. Felling down because your mum just died? Have a cup of tea with Maureen our counsellor. Need your dressing changed? John the nurse will be happy to help. A GP should only be for medical problems only.

Increase nurse practitioners: these are specially trained nurses that can do a lot of GP functions, they can carry out any physical examinations, request appropriate tests to aid diagnosis (blood tests, x-rays, scans), refer patients to an appropriate specialist (in the practice or hospital) prescribe medicines and non-medical treatments. They cost half the price of a GP but as a cynical GP friend of mine said ‘They do half the work’.

I ran this post past Dr George O’Neill. While he agreed with my analysis of the problems his view is that any changes to the current system are a waste of time. Some of my suggestions are already being done but he thinks it is not enough. His view is that the entire system is broken and needs radical reform. I am working with him on another post that will explain his vision for a revolution in primary care. This post should be ready in a week or two.

My only concern is we don’t really do radical reform in Northern Ireland. We tend to bumble along from one crisis to the next without any real long term vision. Will Jim Wells be the man to avert the crisis or will the issue be kicked into the long grass like so many other issues in NI?

Let us know your view in the comments below.

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  • barnshee

    The “secret” is to adopt the Russian model
    Train thousands of doctors– increase in supply = competition for jobs =lower costs
    (i know the docs won`t like it)

  • Gopher

    After my experiences over the last few months I think the only way is allow people to opt out of the NHS. A causal look round any hospital or GP waiting room shows a total disregard for personal health and it’s breaking the system. I don’t want to pay another penny to sustain that

  • Brian O’Neill

    Well you can opt out. There is private GPs and healthcare.

  • Gopher

    Do I get a reduction in my taxes because I’m no longer a drain (sic) on the system to pay for Private care. Presently I’m paying for a system that I don’t get to use because it’s broken and no amount of money will fix it. As for free prescriptions, Chemists now are complete with shopping trolleys.

  • what concerns me

    In reply to your article, I would like to give my thoughts on the subject

    The first biggest hurdle to being efficient and effective is that we do not have a joined up service – pretty much like all our services here in Northern Ireland.

    They remove A&E departments making it that you have to “travel” to a department. Now this would be fine and good if you live on the mainland where public transport runs right through the night – ours effectively closes down at 9pm. There are less cars per capita in NI than anywhere else in the UK, so put this together with an ineffective transport system and A&E depts are harder to access out of hours. Our out-of-hours premises for built up areas are usually further away than most A&E’s, and the wait can be just as long.

    If I wish to see a doctor of my choice in my practice, it will take a 6 week wait. My own GP is a fantastic doctor, sometimes too good a doctor. He works in an under privileged area, he knows the ravages of cancer, the illnesses borne of poverty, the loss of children, the woes of dementia, the fears of the mental illness and the threats of suicide and all of that before we get down to the nitty gritty of GP roles. He cares deeply for his patients, hence why the elderly & the lonely make standing appointments to visit with him, which is why I cannot get to see him before a 6 week wait. They make these appointments because they no longer have back up services. My surgery has a counsellor on site but there is a waiting list for this service.

    There have been cuts to Community Nurses, Community Psychiatric Teams, so where are the people who need these services going to turn? To the GP? – well they could if they wanted to wait 6 weeks, or sit in a crowded waiting room not knowing which doctor you will see, and usually turns out to be a locum who will basically be covering their asses and adhering to all Trust policy – which usually means another appointment will be needed to get correct treatment. So it seems a visit to the A&E will be required as you can just turn up there without an appointment.

    Triage is supposed to prioritise patients, but because waiting times are long – you are usually taken in the order that you arrive, unless it is via ambulance and then you tend to be prioritised, but this is not a given.

    If all GP surgeries were joined up to A&E’s with regards to appointments, (they are joined up with regard to xrays, letters etc) a Nurse Practitioner could make a decision if the patient complaint could wait until the next available GP appointment and make it accordingly, with the patient leaving the dept knowing that some sort of action has been taken. This however would need the GP’s to give up control of their diaries.

    Doctors moving to sunnier climes, you can understand – but doctors preferring to work in war torn areas with Medicine San Frontier (MSF) than leafy suburbs of Belfast is harder to understand. However, MSF do not have as big a problem getting qualified doctors to work in emergency medicine as our Health Minister & his cohorts do, despite the fact that they are offering more money.

    Could this be because, that apart from being put under immense pressure, they do not feel appreciated?

    So we think that by keeping medical talent in the Province will help – well how about a bursary for medical students, similar to that which the Army, Navy & Air Force have in practice? Knowing our lot, they are re-actionists, not pro-activists. They want a return for their money immediately. Add to that, the fact that we are not allowed to have an opposition in government, each of the departments portfolio’s could be held by a rival party, which does not make for good co-operation.

  • what concerns me

    it is your national insurance contributions that fund this – I think you can part co-opt out as a full co-opt out would affect any pension – should a private one fall apart

  • Sharpie

    Really interesting topic. There are two solutions that re needed:
    1. short term
    2. long term

    We need to start with the long term as that will at least allow people to agree what direction we need to be headed in and therefore able to cope with what needs to happen in the short term. In the long term the biggest challenge will be getting people to take responsibility for their own health management and drastically reduce the medical model of health intervention. To get there it has to be managed as abandoning people as is happening now will not work. People need both incentivised and sanctioned. Incentives could include subsidised healthy food or lifestyle options (gym membership, complimentary therapies, proactive engagement in social activities, diet club of your choice, cooking lessons – basically stopping the drivers of ill health).

    We need to be mature about what we can expect to pay for and when stuff becomes unaffordable. there is a local campaign to keep a local hospital open – despite it being hard to staff, expensive to run, and a lower quality that the bigger places in the city. The acute services need to be where there is expertise and quality staff. My mother had a hip replacement and was in such pain and on a waiting list so long that she paid for it herself – it cost £6000 and with absolutely no aftercare – but she was willing to do this. She was operated on by a consultant who also works for the Health Service and cared for by agency nurses who also work for the health service. this place does loads of sub contracted work for the Health Services – there are 150 doctor plaques on the reception wall – all renting space in the facility on a rotating basis – like hot desking with an operating table.

    The short term fix has to be a crisis war time type intervention to highlight the bottle necks and pour effort at those. There are probably five or six key things that will make a huge difference and I imagine that sorting A and E is the place to start.

  • Old Mortality

    The growing proportion of women is a potentially serious problem. Doctoring is in danger of becoming seen as the new and better alternative to teaching for women of intellectual ability but limited ambition. Apart from the guaranteed two months off in the summer, it has all the convenient ‘flexibilities’ that only the public sector provides.
    On the matter of welfare issues, GPs should never be allowed to assess their own patients because of the obvious conflict of interests.
    Maybe it’s also time to consider whether GPs, who are principally just gatekeepers, really require a collection of A* followed by an expensive and lengthy medical education
    By the way are those refugees in Australia paying off their loans?

  • barnshee

    can`t op out of NI contributions

  • what concerns me

    totally agree with a lot of what you have stated, but getting those in power to see it, is another matter entirely. Gym membership was offered for those suffering depression & it was working, then they pulled the plug on it – they want results now and only work for the short term whilst telling us that its all for the long term good

  • Zig70

    Some good solutions, Sound obvious, so why aren’t they being implemented. Find that out and you’ll start to address the issue. Self protectionism. I take issue with the beurocracy whinge. A common complaint from lazy workers everywhere. The public would rightly go nuts if mistakes where made and nothing was recorded. Also management without targets is just dumb.

  • Practically_Family

    Crisis intervetion invariably means crisis level spending.

    It’s not coming.

  • chrisjones2

    They have seen a 10% increase in patient load PER SURGERY – wow, what a shocker that is. Now of course ,many of those patients are older but many are also dealt with by nurses rather than GPs personally. and GPOs have seen a huge increase in salary on the current contract.

    So what is the problem? Well my own surgery has now introduced a 3 week limit on appointments? Why? well in part its the elderly well. The go in for a check come straight out a book a new appointment at the next opportunity. Its a lifestyle choice

    Start charging a fee for appointments. That is the only way to force a sensible control on this

  • Practically_Family

    Wouldn’t you have to find thousands of people who want to train to be Drs in a more competitive and lesser valued market?

    I foresee problems.

  • Sharpie

    I disagree with your analysis.

  • Practically_Family

    It’s sometimes necessary though. An SSRI for instance cannot be put on “repeat prescription” it’s necessary to have a (alrgely ass covering) consultation for each script. In that instance it’s necessary to make a fresh appointment as you leave the current one…

  • New Yorker

    The number of consultations per year seems much too high. Almost 7 versus 3-4 in England and 3 in the Republic. If the number per year were 3.5 there would be 50% more time for doctors. The reasons for the high number of consultations per patient should be investigated. Are people in NI really more than twice as ill as people across the border?

  • Practically_Family

    I’d be willing to wager that the reason is related to the answer I’ve give Chris below.

    Anti depressants.

  • Practically_Family

    Grand so.

    I doubt that it’s going to make a substantive difference to policy.

  • Sharpie

    Thats not so certain. A crisis will spark action and that will be a crisis response by definition. It depends at that stage how it is managed. If there’s no money it will be a crisis response without extra spending. If there’s no credibility in the leadership (Minister) it will be a mess. But it could be better – At that stage people will look at what resources are already in there and how they can be redeployed for short term reaction. An emergency response for a Health Service in acute crisis and a longer term prescription to get it fit for purpose.

  • Brian O’Neill

    But is there not tens of thousands of people who have been on repeat prescriptions for valium etc since the 60’s?

  • Brian O’Neill

    I think the gym membership scheme is still going is it not?

  • Brian O’Neill

    There could be several reasons:
    -It is free so people abuse it more.
    -A legacy of the troubles – lots of people with physical and emotional injuries.

    The weird thing is I go to the doctor once every 5 years. Most people are healthy so if the average is 7 times a year some people must be at their GP every week.

  • Brian O’Neill

    I plan to look at GP training for a future post. It takes 10 years to train a GP, at a cost of half a million each. There must be a better way. http://www.dailymail.co.uk/news/article-2784318/The-doctors-exodus-They-cost-610-000-train-3-000-year-leaving-life-sun-Australia-New-Zealand.html

  • barnshee

    Not really the med schools turn away dozens of qualified wannabe docs every year

  • chrisjones2

    Those who need it should have consultations but its almost a form of recreation for some patients. I know – I count some of them as family and freinds!!!!

    i should love a GPs view on this

  • what concerns me

    don’t think so – it was initially for 3 months & just did a quick check & not available in NI but available on mainland esp for obese

  • Brian O’Neill

    Technically you can if you are a director of a Ltd company which tens of thousands of people in NI are: http://holdenassociates.co.uk/directors-pay-2014-2015/

    I never understand the point of National Insurance. Why is it not just rolled into general taxation? Does it really affect your eventual pension?

  • Pete

    I’m always sceptical when people cite “long hours” as a reason that people aren’t going into GP.

    Certainly amongst medical students and trainees (I was one once), the money and hours of GP are seen as the positive factors of the job.

    Whilst I’m not saying GPs have it easy, the perception amongst medical students is that being a hospital doctor is a more demanding job in terms of time. For example, GP is often cited as a good career for a woman wishing to have lots of family time to go into.

  • Pete

    Lots of jobs are already competitive for doctors. GP tends to be less competitive, because they need so many of them.

    Also, introducing such a system would just put people off going into medicine in the first place.

  • Pete

    Turning them down pre-uni is very different to putting thousands of unnecessary extra people through a 5 or 6 year course for them to have no job at the end of it…

  • Reader

    National Insurance only applies to earned income, not to pensions or investment income, so it’s difficult to roll into income tax on that account. Plus there is the employers contribution to NI, which could be retained in a reform, I suppose.

  • what concerns me

    I agree but to have 2 smaller amounts taken in comparison to one large one makes us more compliant. A bit like offering a car for sale at £9,999. Two smaller sums are more attractive

  • what concerns me

    doing it in piece meal might be an idea – nurse, nurse consultant, nurse practitioner then onto higher things

  • Korhomme

    A fascinating post, Brian. I’m not close enough to know exactly what the problems that GPs face are, but others are:

    http://www.resilientgp.org/inappropriate-demands/

    Just read through the list of “complaints” that people present to their GPs with, it’s as amazing as it is alarming.

    I’m well aware that becoming a GP is no longer seen as a worthwhile profession today. In the ‘good old days’, the GP lived above the shop and was often a family friend. He—it was always a ‘he’ then—was available all hours, but unless there was a major disaster you didn’t call him our to attend. Nowadays patients ‘know their rights’ and expect immediate response to the most trivial, ridiculous and frankly non-existent problems.

    Some suggest that part of the problem is the expectations of today, that there is a ‘pill’ for everything, that the GP can cure everything, all the tiresome problems of life; or that the breakdown of the nuclear family plays a part—where grannie is no longer available as a source of common sense reality.

    One part of the problem is that so many patients seem to have so little faith in the abilities of their GP, and expect a referral to an ‘expert’. GPs in the UK have been traditionally seen as gatekeepers to investigations which are only possible in hospitals. There has been some change in this, in that GPs can refer patients for specialist tests, but yet patients want and demand the reassurance of a ‘specialist’. GPs are specialists in their own right.

  • Korhomme

    Let me give you an example of how hard it is to be a GP.

    If you go to your GP complaining that your nose goes bright green when you pee, you are likely to be dismissed as a nutcase.

    But if you complain that your nose goes bright red when you pee, there might well be a problem:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1879157/

    Now, do you get it?

  • barnshee

    see above— lots of wannabes – churn them out– let them set up new GP practices flood the market

  • barnshee

    Sadly wrong- income taken a a dividend has no NICS applied the but then no NICS means no contribution to old age pension (see below)

    Any SALARY taken is subject to NICS (employer and employee) (There are not tens of thousand of directors in NI)

    You ARE correct in that NICS originally set up to fund NHS/pensions/Dole has -like road fund tax “been rolled into general taxation” and boy does it affect you pension -fail to contribute enough years and your OAP will be much reduced

    A study of how NICS is assessed and calculated will show why just it can`t just be consolidated into general tax

    HINT OAPs don`t pay NICS on their pension what would happen if NICS were consolidated?

  • Korhomme

    Another, real life example:

    “Doctor, I have bags under eyes under my eyes in the mornings.”

    Well, don’t we all? Specially if it’s the morning after.

    But this man had a protein loosing nephropathy (a disease of the kidneys), meaning that he peed out protein, making him more susceptible to a concomitant effect, odema, a collection of fluid; when recumbent this would give him bags under the eyes.

    Now, do you understand how stressful and difficult it is to be a GP? Just occasionally, amongst all the strange, non-existent problems, something weird is actually a real problem. You have to be really sharp to pick this up; and keeping sharp all day amongst the dross is what really wears you out.

  • Korhomme

    National Insurance was designed, originally, to pay for welfare such as the ‘dole’. It’s now really a part of general taxation; the number of years you have paid NI is reckoned when calculating the state pension; you must pay for 30 years to get a full pension. The base rate of income tax is 20%; were NI to be added this would then be 32%, which sounds far worse. NI is calculated rather differently to income tax, so that there can be income levels that act as ‘poverty traps’.

    OAPs don’t pay NI on their state pension; but if you are one, and are hospitalised, it will be reduced.

  • Wils

    at the minute we churn out hundreds of lawyers each year that we don’t need – give them a steer in a different direction?

  • Kevin Breslin

    What about South of Ireland recruitment … or are wages more attractive there?

  • AndyB

    I think there was something available in NI.

    The problem is that approaches such as gym membership to help keep people healthy (ie preventative care) always get squeezed when budgets fail to keep pace with the rising cost of providing curative care – and between new treatments, staff costs, technology and red tape this will tend to be higher than CPI inflation. Rather like most things in that way.
    But yes, what is needed is the money to provide a holistic proactive approach that reduces the numbers of people getting sick and needing reactive curative care in the first place – something which frees resources for those who need reactive treatment.

  • AndyB

    Short version is that National Insurance is a tax on employment. People under pension age pay it from their wages, and employers pay it on the wages of all employees of any age.
    The threshold for paying NICs on any one employment is roughly what the Income Tax personal allowance would have been if the personal allowance hadn’t been increased to £10,000 – the two thresholds were pegged together until some years ago, but NICs are paid from scratch on each employment and Income Tax is paid on the total of all income.
    Employees over pension age don’t pay NICs, the self-employed pay a far smaller amount to maintain their state pension and JSA/ESA entitlement, and those on certain benefits have credits paid towards their national insurance record on their behalf so they don’t lose out.
    I’d suggest they are keeping NICs and Income Tax separate partly because of the impact on the self-employed, but particularly because of the impact on pensioners who would suddenly see their tax going up a lot if NICs were rolled into income tax, causing a governing party to lose a lot of seats at the next election.

  • AndyB

    That’s no longer true. State Pension is now only stopped if you are sentenced to prison for a criminal offence – far simpler.

  • Korhomme

    Thanks, I didn’t know that. Rather reassuring for me…I’ve no intention of seeing life in Clink.

  • AndyB

    The problem is that you wouldn’t reduce the costs at all. If you cut salaries for new entrants, even more doctors will just go and get better paid jobs in Australia. I think that the point about doctors working elsewhere identifies a retention difficulty, and that is usually dealt with by incentives to stay here – AKA more cash.

  • AndyB

    That would take a lot longer – my understanding is that despite the common elements that nursing, and for that matter, paramedicine have with medicine, to transfer to medicine would require so much of the doctors’ study and training that they would more or less have to start from scratch anyway.
    Still worth asking the question of what a conversion course would look like, though, and whether it would still take a full five years to get your MB before moving into the medical training system.

  • what concerns me

    totally agree, many surgeries on mainland are using more holistic approaches to treatment – not sure how that fits in with their budgets. Offset paying gym membership to seeing doctor for medication, prescription, chemist & ongoing support counselling – it would seem like a no brainer – but our reps want results before that implicate new systems

  • AndyB

    Are they still running as much of the preventative stuff as they would like, though, or have they been cutting in the same way?
    It’s a false economy, as we all know, because preventative measures can also result in early intervention when things do go wrong but are cheaper and easier to fix (see also Crime Prevention schemes resulting in more burglars being caught as well as there being fewer victims of crime) but when there isn’t enough money to do things right, reactive care will always have to be the first priority.

  • AndyB

    I expect the official position is a recognition that just because you’re a hospital in-patient doesn’t mean the bills don’t have to be paid, but of course not stopping it means less administration to look after customers who are more likely to be in and out of hospital than the general population.

    I should say that State Pension Credit, being Income Support for the over 60s, is stopped while you’re in hospital.

  • what concerns me

    no all cut but they keep a patient client council going which is run by the health service ni to investigate the health service ni – you couldn’t make it up