Skip to main content
NCBI home page
The Ulster Medical Journal logoLink to The Ulster Medical Journal
. 2024 May 3;93(1):3–4.

Northern Ireland Healthcare Crisis

Laura McDonnell 1
PMCID: PMC11067313  PMID: 38707976

Continuing our series offering a platform to a wide range of doctors across Northern Ireland, reflecting on their current role, and the ongoing crisis in healthcare provision related to the COVID pandemic and political instability in the province. In this issue, three experienced general practitioners working outside Belfast give personal views on their careers and the challenges they face.

David J Armstrong, Editor

Having trained in Queens & completed my hospital years in Belfast I made the decision to return to my home county of Fermanagh in 2005. I always knew I wanted to live and practice rurally and during my GP registrar year my passion for family medicine was nurtured. My GP trainer, Dr Michael Smyth, was one of a few remaining single-handed GPs and instilled in me a true respect for the value of continuity of care. Patients of the small village practice were equally appreciative of seeing a Doctor who knew them and their families ‘inside out’. Those halcyon days had sacrosanct ‘whole team’ tea-breaks around a cosy kitchen table and lunchtime home visits to farms - reminiscent of an episode of All Creatures Great and Small! Long before the advent of GP Federations Dr Smyth and his colleagues had recognised the importance of collegiality when they established the Fermanagh GP Association. This fostered close links between primary and secondary care and lunchtime hospital educational meetings allowed GPs and Hospital colleagues to learn together. Many clinical problems were often solved by a quick telephone call to a colleague for advice rather than a referral letter.

I have been a GP partner in Irvinestown now for fifteen years and have witnessed a lot of change in that time. With retirement of GPs and inability to recruit younger GPs maintaining continuity of care is being tested by the demise of smaller single-handed practices, practice mergers into large ‘super-practices’ and the necessary use of alternative ‘rescue’ contract holders. Out of 17 GP Federations in NI 7 areas have greatly benefitted from expansion of the Primary Care Multidisciplinary team (MDT) to include First Contact Physiotherapists, Social Workers and Mental Health practitioners. It is disappointing however that further roll out has stalled creating an inequitable divide between practices with and without MDT support. GP Federations have been instrumental in Primary Care workforce development. GP Pharmacists are now firmly embedded in all practices and are making a huge contribution to improving the efficiency, quality and safety of prescribing. Many Practices have also taken on the training of additional Practice Nurses & Advanced Nurse Practitioners(ANP). I am a GP trainer and within my practice we currently have two GP trainees, an ANP trainee and two year 3 University of Ulster medical students attached. Despite the workload and workforce pressures rural GPs are prioritising educational activities as they recognise the benefits of improved team morale and that it is essential to sustaining the primary care workforce.

I am fortunate over the years to have maintained close links with my secondary care colleagues in Southwest Acute Hospital. Gone are the days that we have time to travel into Enniskillen for lunchtime meetings but once a month we do make a commitment to get together virtually via the ‘Mind the Gap’ Project ECHO network. I co-chair this zoom meeting with Professor Max Watson and network participants across the primary-secondary care interface co-design an educational curriculum every year, sharing through case-based learning and providing peer to peer support and encouragement. Through the COVID pandemic this network moved to weekly meetings and became a lifeline for us all.

COVID indeed triggered a lot of change within primary care in that most patient contacts are now triaged on a daily basis with queries then more appropriately navigated to a range of healthcare professionals and admin staff. The role of the GP therefore has adapted to a more supervisory and leadership role mentoring colleagues, trainees & students. Another consequence of this filtering of demand is that the complexity of the GP caseload has increased. We are seeing frailer patients with multiple comorbidities in conjunction with polypharmacy, complex social problems and end of life care To reflect the fact that GPs are working at the top of their game some have advocated for a re-branding to ‘Primary Care Consultant’. With so many other specialities becoming so sub-specialised I wonder if this could re-invigorate General Practice as the truly holistic speciality it is and encourage more new Doctors to enter GP training?

Irvinestown, the town in which I both live and practice, is a small town on the border of Fermanagh and Tyrone. Despite being an area of deprivation it has a very strong community ethos and we are fortunate to have the ARC Healthy Living Centre embedded at its core. Not long after moving home I was invited to sit on the board of this community organisation. I admit I was naïve about what this would entail. I had read about Michael Marmot and his teachings on social determinants of health but didn’t realise how formative this journey would be. Working at the grass roots community level gave me a true grasp of health inequalities and population needs assessment and spurred me to take up roles on the Local Commissioning Group and later Integrated Care Partnerships. Through the ARC I saw how problems such as addiction, post-natal mental health issues and food poverty were translated into local solutions of outreach clinics, Surestart programme, and Food banks to name just a few. Early exposure to such community organisations at student and GP trainee level has the potential to embed and normalise social prescribing into the consultation.

We are constantly hearing about cuts to the health budget but forget that so much of the activities that contributes to good health and wellbeing are provided by our colleagues in the community and voluntary sector and widespread cross-departmental budget cuts are having severe impact here too, particularly with regard to early intervention and preventative activities. I welcome the tentative steps that are being taken currently to move towards an Integrated Care System for Northern Ireland. This will bring together a range of partners to take collective responsibility for planning health and social care services with the aim of improving health and wellbeing and reducing health inequalities. There is no doubt that in the current financial and political environment this will be a challenging task but I look forward with enthusiasm to see the outworking’s of this new way of working.

Ten years from now I envisage that Primary Care will look somewhat different. We may have to accept that there may not be a GP practice in every small village or town but the service we receive will be of high quality, outcome focused, delivered by a team of motivated multidisciplinary professionals and led by GPs (or Primary Care Consultants). There will be better integration of care with our community and voluntary partners. With more medical students having spent a greater proportion of their training in primary care there will be a greater research focus and a blurring of the primary/secondary care interface aided by joint multi-morbidity outreach clinics. This supportive learning environment will nurture trainees of all disciplines while providing care for our complex ageing population.

Footnotes

UMJ is an open access publication of the Ulster Medical Society (http://www.ums.ac.uk).

Ulster Med J. 2024 May 3;93(1):3–4.

NI Health Care Crisis –A General Practice View – “A plague on all our houses?”

David J Johnston 1

I have been a GP for over 30 years and for me it remains an exciting, stimulating and fulfilling job. When asked what GP’s do I usually say GP’s are ACE in that we manage the Acute, the Chronic and Everything else. No two days are the same and I still do (a few) out of hours sessions. Medicine and General Practice in particular is a career choice that I would absolutely recommend. That having been said it is clear that in recent times our health service is facing challenges, perhaps even a crisis, that potentially presents an existential threat to the NHS as we know it. The NHS was set up to provide comprehensive universal health care, free at the point of delivery, for everyone in society whatever their need. It has been said that to accomplish this “ranks as one of the greatest achievements of civilisation.”1

General Practice has a national profile but local delivery. Almost every community has their local practice and people relate to that. General Practice is, or perhaps was, the front door and the shop window of the NHS. Much of what General Practice does is intangible and often hard to measure or quantify but the management of undifferentiated, undiagnosed, and often undiagnosable patients who are ill or who perceive themselves to be ill is the core skill and involves managing uncertainty and carrying a level of risk that makes a health service that is truly free at the point of delivery possible. There is ample research to demonstrate a direct correlation between the strength of a nation’s primary health care system and enhanced health outcomes and a more cost-effective system as a whole.

Over the last 30 years, in my view, we have seen a loss of partnership working. We are struggling to hold on to core skills, attitudes, values, and behaviours. For a variety of reasons, our health service is less cohesive and there are real divides between and within secondary care, community services and primary care services. Even primary care itself is now splintered into “In Hours” and “Out of Hours” care. There are very real difficulties accessing General Practice and patients do genuinely feel that the NHS is less caring than it once was.

The situation will not be improved by fragmented thinking or by criticising individuals or specific groups. It is our NHS whether we are patients, politicians, policy-makers or indeed the professionals working in it. We need to find common cause and thereafter work in partnership to agree a clear vision that creates a “landing ground” agreed by all. We need to create systems that promote a continuum of care where patients move backwards and forwards along seamless pathways according to their need, aiming to make the idea of “teams without walls” 2 a reality. The demands of managing the pandemic demonstrated many successes that stemmed from a focus on partnership working.

Patients need to have a realistic expectation of what a service can and cannot provide. Politicians must provide leadership and articulate reality avoiding the temptation of a short term populist approach. Policy-makers need to ensure finite resources are used to optimum effect and champion evidence based long term strategic thinking. The professions must accept that while they are busy they may be busy doing the wrong things and that additional resources must come with enhanced productivity and consistency of outcome.

By way of illustration consider the unintended consequences of a strategy that was ill considered - “Free prescriptions”. The outworking of this policy is that every day practices are issuing prescriptions for items such as paracetamol, which can easily be bought in a local shop at a cost of a few pence. However, when processed through the mechanisms of a practice, issue of a prescription, pharmacy involvement and dispensing of the drug it results in a cost to the health service of perhaps £40-50.

In reality this means that for every 250 paracetamol scrips issued we could instead fund a total hip replacement operation. So simply stopping so –called “free” prescriptions for paracetamol would allow the NHS to provide 200 -300 more total hip replacements in Northern Ireland each year at no additional cost.

So what is the future for General Practice and by extension the NHS? I believe that General Practice and the wider NHS can have a bright future and that GPs can still be ACE if our focus is on providing Access, Continuity and Equity for our patients.

As a health service we are sometimes so busy doing the urgent, we miss the important. We must develop partnerships and proceed with vision, purpose, and courage. The degree to which we succeed could be a defining issue for our generation. As Abraham Lincoln said: “The best way to predict your future is to create it.” As a society we must do better and we can do better if we all work in partnership to create that future because in the words of the song, “You don’t know what you’ve got till it’s gone.”

REFERENCES

Ulster Med J. 2024 May 3;93(1):3–4.

A View from the Coalface

Nicola Duffy 1

We have been cancelled.

Patients complain. (‘She won’t see me’)

Appointments (‘She sent me to a physio / pharmacist’).

Waiting times (‘He wouldn’t do me a letter even though the secretary said it would help’) Prescription shortages

(‘The HRT you gave me wasn’t available’).

PIP rejections (‘They said your letter wasn’t strong enough’).

Too many antibiotics leading to resistance. (‘She just throws antibiotics at you’)

Not enough antibiotics (‘She says everything is a virus’)

Too many anti-depressants handed out ‘willy-nilly’(‘She just looked at me and wrote a script’)

Too many being people being sent for ‘talking therapies’ instead (‘He gave me nothing’)

Just as the remit of the GP is seemingly endless so too is the list of things we are seemingly responsible for.

The NHS is on its knees and we are all morally injured. We need to do the work on that collectively and revisit the simple act of collegiality and respect. We need to stop criticising General Practice - to each other, to our patients, to medical students.

So what is GP like for me?

I still love it and love my patients. I love the continuity.

I am at the coalface and have agency.

Maybe it’s that agency that encourages the discord. I’m not wedded to a clipboard yielding manager.

I am lucky to have many Secondary Care colleagues as social contacts - this is what keeps me from professional despair - every time I ask for advice / support I feel their connection to my concern, my worry, my patient - it keeps me sane in these dark times.

I feel for the junior doctors – there are poor training environments, unstable teams, exhausted team leads, and ward round ‘safaris’ where education must be compromised. I can appreciate the issues my colleagues experience but I don’t feel this is always reciprocated.

So, to be blunt, don’t blame General Practitioners for all the ills of the NHS. Let’s do the work folks, step up and look after each other. Doctors in conflict is exactly the narrative that enables the constructive dismantling of the NHS.

Be curious about my job, not judgemental!

Articles from The Ulster Medical Journal are provided here courtesy of Ulster Medical Society

RESOURCES