The 2004 GP contract was the result of significant problems in English inner cities with recruitment and retention of GPs. The continuity of care the bedrock of general practice was lost when GPs no longer were required with the implementation of the new contract to provide out of hours medical services. As a consequence patient care is now the responsibility of the Trusts for the majority of the time. The loss of continuity of care means the GP is no longer the proxy consumer for the patient and also lost is the GP gatekeeper role for the Health Service. The days of the family practice are in my view numbered and the previous long term relationships built up with individuals and families have melted away.
General Practice is at a tipping point with increasing demands raised patient expectations and the transfer of work from hospitals to General Practice without any resources. There are 349 GP practices in Northern Ireland and 1171 GPs 55% are male and 45% female (2013) and we have the lowest number of GPs per 100,000 (61) than any other part of the UK. GPs account for 3% of the workforce and deal with 93% of first contacts within the health service. This for the most part quality service is delivered at bargain basement prices approximately 6% of the NI Health Care budget around £240 million from a budget of almost £5 billion. Despite having greater health needs than the rest of the UK GP funding in NI is 2% less than the rest of UK. In order to bring the Province up to the UK spend £33 million is required recurrently in addition to the almost 7% annual uplift to cover NHS inflation.
Family practice in NI is facing the perfect storm increasing demand fewer GPs lack of investment. the premise GPs can cope with the transfer of work from hospitals so-called shift left and the development of new treatment pathways without consultation with Family Practitioners.
In the last ten years the consultation rate has doubled which is equivalent of 7 consultations per patient per year. Add 20 prescriptions items per patient year, a 217% increase in laboratory tests and a 42% increase in repeat prescriptions. This rapid increase in work load is unsustainable in the long term.
I was trained in acute episodic curative illness model of care and patients with chronic illness and diseases had their care delivered at Medical Out Patients. Unfortunately we have lost the hospital based generalist bar the geriatricians and GPs are required to have knowledge across the full range of patient problems. The acute model is still used to provide care for patients with chronic illness multiple co morbidities and polypharmacy. I posit it is challenging to deliver care to these increasing number patients with 10-minute appointments.
The present model of delivery of General Practice was developed in a different century with different demography a different workforce different expectations different investigations and different treatments and is no longer fit for purpose.
General Practice will not be saved by throwing money at it but needs radical change sooner rather than later. The development of GP Federations opens many opportunities and will result in closer working relationships developing between not only the member practices but also with Trusts the third sector and the other social determinants that contribute to our health and wellbeing. The aim I suggest is to develop not only a vertically integrated system but also horizontal integration.
The vision the Federations need to develop must be patient orientated and outcome focussed. The Federations do not have a trade union function and have no role in improving GP working conditions as this is the role of the BMA.
Bengoa and the expert panel have indicated the way forward and it involves the need for all members of the health service family to accept change and focus on improving outcomes for patients and service users. This cultural change will be difficult to implement and the lack of leaders especially those willing to have courageous conversations may delay any progress.
There is no single solution to the problems of GP land and rural and urban practices single handed and group practices need different approaches. Geography population makeup rurality and staffing problems will all influence any resolution.
The Minister has produced a 10-year plan which is radical and forward thinking but General Practice cannot wait and many practices are barely coping at present. Over fifty practices have written to the Minister and the HSCB drawing attention to the challenges they face and asking for assistance. The majority of practices are in a similar situation with Fermanagh and Tyrone facing particularly acute problems as GPs retire. The demanding workload a lack of locums fear of ligation and a risk adverse culture combined with lack of resources and a significant drop in practice income has made General Practice unattractive to young doctors.
I fear unless GPs accept change, patients accept they have to become responsible for their health and politicians accept they are often more of a hindrance than agents for change within 2-3 years the family practitioner service will have collapsed. To be continued >>>>>>>>>
Dr George O’Neill in a GP in Belfast
BBC Spotlight is covering the GP crisis in tomorrow night’s programme. Here is the trailer: