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.