Continuity of care and relational expertise to deliver excellent whole patient, whole of life care for all our patients is a priority for GPs in Northern Ireland.

Patients trust and value that relationship with their family doctor and there are many good reasons to do so. With continuity of care, patient health outcomes are better, a patient has fewer hospital admissions and unnecessary investigations, there is increased satisfaction, and believe it or not it is good for the health and well-being of GPs too.

But this cannot be delivered without investment.

In his report to NHS England Lord Darzi states that “general practice has the best financial discipline in the health service as they cannot run up deficits with the belief that they will be bailed out”.

An investment in the health of our population that is used well and delivers more cost-effective care for patients really would be an invest to save strategy, with better outcomes for all our citizens and the public purse. For every £1 spend across the NHS, the economy sees a return of £4 pounds, when £1 is spent directly in community or primary care, the return on that investment is £14.

Despite this, relative expenditure in general practice has been eroded over more than a decade and reversing that does not appear to be a priority for the Department of Health.

Shift left, but funding to the right

GPs have grown tired of acknowledgments of a need to ‘shift left’ with more resource to follow, when, in reality, what they have seen has been an unfunded creep of work over many years. Such an investment would see the relative proportion of the spend in general practice increase- this is not what is currently happening; a funding drift to the right has occurred with more money into secondary care for more staff and services. A case of ‘jam tomorrow’ but never today for Northern Ireland GPs.

Shouldering such a burden in general practice has exposed some very dangerous cracks in the foundation of our health service, and it is no wonder that GP contracts continue to be handed back. There were 7 last year, and a total of 45 in the last decade, bringing the number of practices across Northen Ireland to just 305. It is not surprising that two of the biggest drivers for our current situation are financial strain and the inability to recruit. Couple that with the fact that running practices via mechanisms other than that of an independent contractor are costing the public purse so much more as evidenced at a recent Health Committee meeting, when some members advised that they had figures showing a number of trust-run practices costing at least twice as much as the funding which had been given to the previous independent contractor GPs. One must ask the question how can our system afford not to strengthen and stabilise the independent contractor model that has been shown to deliver time and again?

Last year, those independent contractor GPs received on average just less than 50p per patient per day to provide free at the point of access NHS general practice. Based on just released Northern Ireland Statistics and Research Agency statistics, a total of £377.1 million was paid to practices. Even taking the starting budget position of 24/25 as approximately £7.8 billion, my very crude calculations see the proportion of spend in general practices sitting around 4.8%.

I’m sure that every single patient calling their practice for an appointment can feel that squeeze on GP budgets!

There are many factors contributing to the widening demand-capacity mismatch.  A growing population who are getting older with more long-term conditions, meaning a greater need for complex care is perhaps the easiest to articulate and measure but it’s not the only consideration in relation to demand.

What patients experience is the 8.30am scramble on the phone for an appointment that day after day they miss out on. I can assure you that this doesn’t happen because GPs are working any less hard (in fact entirely the opposite in my experience) but because they are one of hundreds calling each day with a similar need and similar frustration.

Those calls are the GP equivalent of the dreadful hospital waiting lists that so many patients must endure. The impacts on patients are manyfold with anger and irritation paling into insignificance when it comes to late diagnosis and poorer outcomes, while hardworking staff bear the brunt of such frustration. General practice staff are burning out, reducing hours, leaving or retiring early.

The time for action

Capacity and by default access, cannot be increased without more people. Of course, there are technological and systems improvements that can be made, but fundamentally more phone lines are of little use without more care navigators, more nurses and more GPs.

While the total number of GPs is marginally rising, the change in working patterns mean that an extrapolation of whole-time equivalent numbers cannot be made. Digging deeper, it is important to note that from 2018 the number of GP partners has fallen by 7% with the increase in headcount attributable to more salaried and sessional GPs.

There is no doubt that NI general practice stability depends on recruiting and retaining more GPs right across the workforce but the trend towards fewer partners is worrying given their key contractor role.

What is stopping GPs from becoming partners? Financial risk, unlimited liability and increasing bureaucracy involved in running a business are but a few of the challenges. That being said, while many of these businesses are as old as the health service itself, as Darzi cited, they have a strong financial discipline. It is not a lack of financial acumen which is failing these businesses, but the squeezing and squeezing of the funding envelope, requiring GPs and their staff to do more and more that is fuelling this change for GPs at all stages of their career. The current added inflationary costs and National Insurance Contribution requirements will mean those prepared to solider on will have to cut the cloth of service provision even tighter to fit.

This is not a picture of stability.

Within the same time frame, the rise and rise of private GP provision serves as a warning. The growing two-tier model will do nothing to alter the widening inequalities for our citizens and the inverse care law described by the Welsh GP,  Dr Julian Tudor Hart more than 50 years ago looms large in 21st century Northern Ireland - those individuals most in need of medical care are often the least likely to receive it.

Neither our patients nor our health and care system can afford for the collapse and failure (piecemeal or large scale) of NHS general practice.

I fear we have moved beyond looking toward “investing to save” and are now in a position of needing to invest “to save” general practice in NI.

The time for action and a change in priority is now.

Dr Ursula Mason is a GP partner in Carryduff Surgery, a large suburban practice south of Belfast. She is Chair of Royal College of General Practitioners NI (RCGPNI) taking up this position in November 2022. Her additional roles include Vice Chair of the Eastern Federation Support Unit, and she is a past Chair of South Belfast GP Federation.

Her clinical interests include women’s health and prescribing and she is a member of the NI Prescribing Guidance Editorial Board and a former clinical lead for gynaecology in the General Practice Elective Care Service.

Ursula is a committed teacher and trainer and passionate about supporting the next generation of doctors, as a current undergraduate tutor and a GP Trainer. She has previously held roles as Programme Director and Associate Director of GP Training at NIMDTA. Her Chair’s priority during her tenure with RCGPNI is “Building a GP workforce that is fit for the future”.