Dr George O’Neill on the slow death of general practice…

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:

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  • murdockp

    Rather than kick the NHS, we have to behave better as citizens. We have a moral responsibility to look after ourselves better and just use the NHS during times when we need it through no fault of our own such as following an accident or an illness.

    When I hear of people not turning up for appointments, continuing to smoke or not take up exercise when advised to do so I despair.

    But we are at the end product of what our politicians have created which is a nanny state where we have delegated personal responsibility to others as we struggle to lead our own lives without involvement of the state and any thing that goes wrong is always someone else’s fault.

    I admire GP’s greatly but I couldn’t do their job as the expectations of the public are frankly, ridiculous.

  • Gavin Smithson

    EveryoneI know can get a GP appointment ok. I don’t there is a crisis despite protestations to the converse. If I don’t see a crisis then it’s hard for me to agree that there is one. People are always complaining about the NHS being at the brink. The boy has cried wolf since 1948.

  • Gavin Smithson

    How dare you ask people to take responsibility for their lives.

  • Zig70

    Can you imagine managing directors on 100k a year looking sympathy for their busy schedules. Especially when my recent experience of gp’s is just google and refer. To me they have priced themselves out. Replace them with nurses and solve the problem.

  • hgreen

    I often wonder why we have to go to our own specific GP practice. Why not have general GP services and just visit the first doc available? These could be open 24 hours so that people could be directed away from A&E.

  • hgreen

    Did you make the wrong career choice?

  • hgreen

    Are you going to draw up a list of what is moral behaviour and what isn’t?

    Meanwhile back in the real world taxation should be used to reduce and pay for risky health choices. Smokers already pay additional tax that should be used to contribute to their future treatment.

  • Zig70

    You bet, I’d have to make MD in a private company to match their salary.

  • chrisjones2

    …and usually for less work / more money

  • John Collins

    I would suggest one needs to endure a much longer and more intense training schedule to be a GP than to be a MD of a company.

  • Peter Moore

    I received notice just over a week ago that my own practice
    is closing down as they cannot find a GP to take it on. The previous (practice titled) GP is retiring (as an aside he spent his holidays travelling to African countries
    and giving free medical care at his own cost, so it gives you a measure of the calibre of physician and man he is/was).

    I have both family and friends who are Dr’s and nurses and they all, independently of each other, have told some utter horror stories about the pressure they are under, this includes but is not limited to: the debacle of ‘declare incidents’ and A&E, the hours they are expected to work, the behaviour – from both senior management and the public – they are expected to tolerate, access to adequate resources.

    I think unless actually working in the system, one might not see a crisis, but that doesn’t mean there isn’t one.

  • Brian O’Neill

    Indeed and it will be be the last to shut. I am always amazed that when we run posts that directly affect peoples lives we get very few readers. But run a post on flags or the usual trigger subjects and we will get 5,000 readers.

  • Brian O’Neill

    I wonder this as well. I don’t care who I see as long as they have a medical degree and wash their hands.

    For chronic conditions I can understand Continuity of care but for all the minor ‘whats this rash’ queries why can’t I just rock up at some minor injuries clinic?

  • Doctor M

    In parts of England you can. The problem is that they’re largely staffed by non-medical practitioners who will probably refer to hospital or A&E for your minor rash. Your GP might not know what it is but will know whether it’s serious or not and will probably be able to come up with a sensible plan and review if necessary. Continuity of care is vastly undervalued and probably saves the NHS billions!

    The other big advantage of continuity of care is that your GP builds up a picture of you over the years helping to put symptoms in context. Sometimes a pattern of seemingly unrelated presentations can sometimes lead to a bigger diagnosis.

  • Doctor M

    I think smokers are regarded to be net contributors to the exchequer as they pay a lot of tax and have a reduced life expectancy thereby avoiding huge social care bills in old age.

  • John Collins

    Absolutely correct. There was a post here on Carson and about 400 comments were added. FFS – hat is dead for about 90 years, is it not high time he was left rest in peace.

  • whatif1984true

    I get that GPs are under pressure. I watched the BBC program which was very poor. Correct me but did they manage to join the dots. Were these questions answered.

    Number of GPs retiring each year for last 10? years versus numbers trained in last 10? years. Forecast retirements looking ahead and forecast GP training places.

    BBC mentioned that all those trained as GPs are not guaranteed a job? How or why is this true?

    Who sets the number of doctors trained each year? How has it increased and is it in proportion to actual forecast needs?

    How many DRs are leaving NI immediately after training? What does BMA think of restricting movement out of NI taking into account the 100’s of Thousands it costs to train a DR?

    The BBC programme was populist fear mongering without attempting to get to the real problem/solution.

    Maybe someone can help better inform us on the above.

    Regarding the lack of response on this type of subject matter vs FLEGS. Slugger has its focus on FLEGS and similar matters. I rarely visit as I find the subjects repetitious and the comments mostly trivial venting. The whole site needs a major overhaul and I’m not talking about software/design/graphics.