The end of free GP access in Northern Ireland is in sight

A couple of years back, I was chatting to a friend of a friend who is a GP. Like, I suspect, most of us, I had (and still have) a fairly limited understanding of the nuts and bolts of how healthcare is actually provided in Northern Ireland, and he spent a bit of time explaining it to me.

I was quite surprised to discover, for example, that GP surgeries are actually private businesses. They’re almost exclusively organised as partnerships, a type of business arrangement where self-employed individuals agree to jointly share resources, profits and liabilities. Generally, they make little or no profit, and operate almost exclusively under contract from the health trust, who provide a fixed fee based on the numbers of patients they have on the books. In other words, primary care (GP) provision is an outsourced function. This is true elsewhere in the UK, although lately there has been a rise in private for-profit corporations taking on primary care work.

I often find myself wondering about those who campaign to “stop privatisation of our NHS” and if they have thought much about the fact that many parts of healthcare provision in the UK are already – and always have been – “private”, ie delivered by organisations that are not either part of or under the direct control of the state. Most hospitals are obviously state-run via the health and social care boards, but this is the exception. Opticians were the first service to have the state provision watered down; lately, most of us are acutely aware that it’s difficult these days to get access to a dentist on an NHS basis. And I’m sure it goes without saying that pharmacists, who provide a vital function, are private businesses in their own right, and very often corporations.

My point here is that the “stop privatisation of our NHS” campaigners are aiming at the wrong target. The issue is not what parts of the service are under control of the state or operated on a non-profit basis; it’s about access, and that is something which is entirely independent of the ownership model. Many (most ?) of the major hospitals in the US, where healthcare provision is famously subject to the excesses of capitalism, are run on a non-profit basis. The fact that they do not return a profit to shareholders helps nobody; it’s the lack of universal insurance, along with a number of other things, that causes the issue.

In recent years NHS GPs have begun charging for certain services that are outside of the requirements of the NHS contract. These include things like vaccinations for foreign travel, or certain medical assessments. It doesn’t seem like much of a leap to charge for other things as well, so I asked the GP what was stopping doctors from doing the same thing the dentists were doing – keeping their NHS function going, but offering paid-for access to those willing to pay a fee. “Nothing”, he replied. It is simply a line in the sand that NHS GPs have so far been reluctant to cross.

There are a few private-only GP surgeries in Belfast (and there seem to be more than there were 20 years ago). These seem to promote themselves on the basis of providing quick access to appointments, or for providing medical advice on issues that people might be too embarrassed to talk to their regular GP about. I’ve noticed that one such surgery has begun offering a payment plan that offers a certain number of GP consultations per year, bundled with an annual health check, much like the plans offered by dentists that cover regular checkups and provide discounts against treatments. GP appointments seem to start at around £60-£70 for a 15 minute session. My understanding is that any prescriptions issued privately are at cost. I know of few people who have used these services but they must be able to operate as a going concern. I can see the attraction for someone who wants a quick appointment, perhaps because they work in the city centre and it is convenient for them.

A few weeks ago, there was an (£) article in the Belfast Telegraph about local senior GP Dr Tom Black, who is also chair of the local BMA. Dr Black has a practice in Derry, and feels compelled by chronic funding shortages to start operating a private GP consultation service under the same roof. He suggests that if the model succeeds, it will be replicated : “I wouldn’t be surprised if [when] they see this new, innovative hybrid practice, a significant number of other practices take up this template”.

I suspect Dr Black is right. We’ve been here already with dental surgeries. Sadly, it also appears to have become the norm that people expect to have to pay or obtain insurance to have elective surgery. Several people in my family, including myself, have had to “go private” for elective procedures due to excessive quoted wait times. We’re lucky to have had this option, but I am aware of other cases where people have had to take out bank loans, borrow from friends or family, or even borrow against their homes in order to get the treatment they need.

Soon your local GP surgery will offer a fee-paid arrangement for patients who want to be seen quickly. Despite being the only region of the UK that does not elect a single Conservative Party politician, it looks like over time we will become the first part of the UK where fee-based GP access will become the norm. We will pay heavily, both financial and in terms of social inequality, for our refusal to engage seriously on healthcare and deliver difficult reforms. The next time you’re voting, make sure you ask your local candidates what exactly they intend to do about this, and pay careful attention to the answer.

(*note : I am using the term “NHS” in the commonly-used form, ie as shorthand for publicly funded/universal healthcare in NI. Pedants will be well aware that the NHS does not exist in NI!)