In his most outspoken and stark comments yet on the crisis facing general practice, Northern Ireland GPC chair Dr Tom Black told GPonline that the survival of the GP service was more important for the community than the principle of the NHS, and that practices could be charging patients for appointments before the end of the year.
The NIGPC is currently working with BMA officials on a mechanism to seek undated contract resignations from practices in response to the workforce and workload crisis engulfing the service. Dr Black said that could happen within the next one to two months, with GPs serving six months' notice on the government before practices leave Northern Ireland’s NHS, the HSC.
GP leaders have drawn up several alternative plans to establish a GP service outside the NHS, but Dr Black said the most likely model would be direct charges for patients, on similar lines to services over the border in the Republic of Ireland.
Dr Black admitted that public reaction to such a move by GPs was a concern. But, he said: 'The bottom line is that the only way to save the GP service at the moment is to leave the NHS.’
‘What we are really saying is that we think that saving the GP service is more important than the principle of the NHS. If you give me a choice, for my community here in Derry, of maintain the NHS but not have a GP service; or maintain the GP service but lose the NHS, the answer is very simple. The GP service is more important than the principle of the National Health Service. It's very clear. The NHS does not exist without the GP service.’
Dr Black’s comments could increase pressure on GP leaders in England who scrapped plans for a ballot on undated resignations in August 2016 after NHS England agreed to talks on the BMA’s Urgent Prescription plan to save general practice. Some GPs have said the GPC executive should go ahead with the ballot agreed by LMCs if there are no concessions within months from ministers over areas such as funding, CQC inspections and workload.
Northern Ireland's GP leader made his comments as news broke of yet another practice on the brink of collapse. The department of health (DoH) announced late on Thursday that it had found a new contractor for the 5,000-patient Bannview practice in Portadown, which faced closure after its last GP resigned.
Meanwhile, NIGPC expects County Fermanagh to be left with just five practices on three sites when 13 of the current 18 close or merge this year.
Dr Black said Northern Ireland’s ‘insurmountable’ workforce crisis meant practices could not be kept open. ‘There are no private providers because there is no workforce for them to employ. And there are very few locums that can be brought in,' he said.
He predicted that the crisis would deepen around the end of March when a number of GPs are expected to retire.
In December the BMA announced that 97% of GPs in Northern Ireland balloted in a series of crisis meetings supported the plan for a mass contract resignation. Just before Christmas the Sinn Fein health minister in the power-sharing executive Michelle O’Neill agreed a plan of action proposed by GPs.
The plan includes increasing training places and developing multidisciplinary teams. But Dr Black said there had not yet been an announcement on funding and, given the latest political crisis engulfing the government, he expects to be disappointed when that comes. ‘I would hope that sometime in January, the DoH will propose a quantum of investment, and given the other organisational exigences in the Assembly, I wouldn't be surprised if I was disappointed,' he said.
‘What happens then is we move forward to collecting practice resignations.’
Partners will be asked, through their practice agreements, to submit undated resignations to the GPC, possibly within the next month or two. Once a ‘critical mass’ of resignations has been collected, GP leaders will give the government six months' notice before practices move out of the NHS.
‘It would be quite an organisational achievement for us to do that in terms of legal, premises etc, and we might have to do it one town at a time,' said Dr Black. ‘I think that might be a very good way of doing it. Because there are some towns such as Portadown and counties such as Fermanagh who would like to do it now.’
The union leader said his door was always open to the government for further negotiations, but ‘we have to recognise there are problems within the system that there may not be solutions for given the political situation we have in Northern Ireland’.
The most likely ‘Plan B’ for practices operating outside the health service would be a ‘Republic of Ireland model’, he said.
‘There are four options we have in our plans at the moment,' Dr Black said, ‘and GPs would have a say in that. But I think if we want to get this done in a straightforward manner, it would be fee-per-item and along the Republic of Ireland model. People understand that in Northern Ireland.’
But Dr Black added that he thinks practices would not be outside the NHS long. ‘How long would we be outside the NHS before we would be brought back in? The answer is not very long. Because the service cannot cope without GPs. And this is not us blackmailing the service. This is us simply saying, once we got to the point where nobody wanted to become a GP, that's when ... you should have fixed this.’