Is Northern Ireland’s primary care system on the verge of collapse?

“It could be like dominoes”

Steven Kinnear, a GP in Bangor, says many of his colleagues feel they could not survive a list dispersal in their area and that the unacceptable increase in workload could have a cascading effect. “That’s the big fear—that it could be like dominoes,” he says. “One dispersal or collapse could take out another practice and that would roll on.”

Mace uses the word “tsunami” to describe this prospect.

The fear is widespread. More than 5000 patients are registered at Mullaghbawn Surgery in County Armagh. But the practice will lose its GP contractor at the end of June and no new contractor has yet been found to run the surgery. GPs at six neighbouring practices have written to the DoH5 to say they are all currently “in crisis.” They emphasised their alarm at the prospect of a list dispersal.

“We are in agreement that the current proposals will destabilise South Armagh General Practice as a whole,” the letter read.

Although it has not yet occurred, the risk of list dispersal is real, says Stout. When one practice, Kells and Connor Medical Centre in Ballymena, handed its contract back recently, letters were sent to its patients and many nearby GPs regarding list dispersal—but this notice was retracted three days later when a new contractor was found,6 he explains.

Between 2014 and 2022, the rate of practice closures or mergers was around four a year in NI. But the past 12 months have been extraordinary, with roughly 14 practices 7 handing back their contracts. Three have new permanent contractors in place, two are being managed by local trusts, and five are undergoing negotiations regarding start dates for new contractors. Three are still subject to negotiations.

The latest to hand back its contract, Kilkeel Medical Practice, posted an update to Facebook in late April that read, “The practice has been operating with half the workforce of three years ago and as a result the management of the ever increasing workload has become unsustainable.”

Service collapse

There are around 30 additional practices in Northern Ireland that are at high risk of joining these 14, says Ursula Mason, chair of RCGPNI. The reasons for a contract handback could include a senior GP retiring, being off work long term because of illness, excessive workload, financial difficulties, or a combination of these.

“We have an ageing workforce and escalating demand,” adds Mason. “You’re seeing services collapse.”

There is a mismatch between the numbers of GPs being trained in NI and the required workforce, she continues. The DoH has committed to training 121 GPs during the current financial year, despite “a very challenging budgetary position,” a spokesperson says. But Mason and colleagues on a task and finish group that looked into GP training estimated that 161 trainees are needed every year.

While GP practices have been closing, or nearly closing, in recent years, the population in NI has been rising, says Stout. There are 70 000 more patients today than there were 10 years ago.

Then there is the cost of running a practice. Utility bills, for instance, are much more expensive because of the cost of living crisis, says Stout. He notes that GPs are often available in an area but none are willing to take on the financial responsibility for a practice.

Northern Ireland GPs pay thousands of pounds a year for clinical negligence indemnity cover. This is in contrast with England and Wales,8 where a state backed scheme is in place.

Crisis measure

It has become so difficult to find GPs willing to retain or take on the responsibility of managing practices that non-profit community interest companies (CICs) have been proposed as a solution in some cases. A local person, such as someone from the GP federation, then becomes the “lead” responsible for a practice.

“This is a crisis measure. It’s not a situation any of us wanted to put anybody in,” Stout says.

One GP who spoke to The BMJ expressed doubt that the CIC model would provide any advantages to maintaining GP practices.

Kinnear argues that, while holding on to a contract can come with its own financial stresses, many GPs feel as though they have no option but to continue because it would be “potentially financially ruinous” to hand a contract back. This is because, as senior partners, they might continue to be liable for staff salaries and the lease on their premises, for instance.

As for the impact on care, Mace notes that it has become much more difficult to find the time necessary to deal with chronic illnesses, such as those commonly experienced by elderly patients, for example.

People in NI often assume that pressures at emergency departments9 are because it is hard to get an appointment with a GP, says Ciaran Mullan, chair of the Western Local Medical Committee. He says, however, that the real problem is the poor flow of patients out of hospitals, meaning beds are not freed up quickly enough.

While private firms have not, as far as The BMJ is aware, taken over any GP practices in NI so far, there has been a proliferation of private GP services in recent years. This includes GP services offered by independent hospitals,10 such as Kingsbridge Private Hospital in Belfast. It registered a 33% increase in footfall across all its services between 2021 and 2022.

Solutions stalled by lack of government

In order to entice more GPs to Northern Ireland, resources are key, says Mason. This includes the wider establishment of multidisciplinary teams at GP practices, incorporating mental health practitioners, nurses, physiotherapists, and social workers, for instance.

Certain practices do have such provisions, including Mace’s, but in some areas it is uncommon. Stout describes the multidisciplinary approach as a “failed project.”

Resolving problems such as indemnity insurance is difficult, not least because of the lack of a functioning government in Northern Ireland, notes Mason.

Mace agrees: “Having no government is a big, big thing.” She says that, in Great Britain, paramedics in some areas are doing home visits.11 Such initiatives, along with better support for people experiencing a mental health crisis and a commitment on the indemnity payments matter would help GPs in NI. “It would make a big difference,” she says.