How GPC Northern Ireland's new chair plans to make struggling practices sustainable

Belfast GP Dr Alan Stout takes up the reins as chair of BMA Northern Ireland's GP committee on 26 September - and it's hard to imagine a tougher landscape in which to take on the role.

It's been around 20 months since the power-sharing government in Northern Ireland collapsed, creating a political vacuum that stopped NHS plans and budgets in their tracks.

Dr Stout inherits an ongoing scheme that has seen the BMA collect undated contract resignations from practices across Northern Ireland - with a view to triggering a mass resignation that could take general practice outside of the NHS.

Although that plan is firmly on the back burner amid a sense that progress is being made around implementing plans for multidisciplinary teams, a rescue system for struggling practices, and an £8.8m boost for general practice under a new 2018/19 GP contract, the profession remains under extreme pressure.

'There are a number of areas that are in real difficulty at the moment,' Dr Stout says.

Struggling practices

Struggling practices in Eniskillen are working on mergers - which have offered a 'degree of solution' to problems facing general practice in the area - but 'remain under massive pressure'.

But Dr Stout - a partner at the same east Belfast practice since 2001 - says it is is a wave of potential closures in his own city that is among the most worrying signs for general practice in Northern Ireland.

'We are seeing very imminent closures in Belfast - we have letters of notification of them handing their contracts back. Each of those have involvement from the LMC and the health and social care board, trying to find a solution - but there is a real risk a solution won't be found.

'This is not about undated resignations - the reality now is we are getting dated ones.'

Resignation

Four or five out of around 100 GP practices in Belfast have handed in their notice, Dr Stout said - with workload and premises clearly the main factors behind their problems. The 'last person standing' issue is a significant part of the problem. 'Largely these practices can't find partners to buy in,' he says.

Although 'a couple' of the practices set to hand back their contracts are single handers, it's not just small practices that are affected. The largest has around 9,000 patients - around 50% more than the average list size for practices in Northern Ireland.

Pressure on general practice, however, appears to have concentrated minds - and Dr Stout is clear about measures being developed to help practices, and about the overall approach he believes will help ensure a sustainable future.

'One of our priorities is contingency planning for practices on the brink,' says Dr Stout. 'There are things they can do themselves - looking at what they do and don’t do, how they manage contracts and staff in the practice. There are also things the health and social care board (HSCB) can do, around new patient registrations, contract easement, facilitating joint work with neighbouring practices or a rescue team, which is starting to get off the ground.'

GP contract

Contract 'easement' involves a decision from NHS bosses to allow a struggling practice not to meet the full scope of its contract - potentially relaxing enhanced service or QOF targets, for example.

Rescue teams, meanwhile, are starting to be established in Northern Ireland to offer emergency support to struggling practices. Dr Stout says the health department has agreed to fund the teams, and that eventually the idea is to have one in each of Northern Ireland's 17 GP federations.

For now, there are a handful operating across multiple areas each - and what they bring to practices is a short-term workforce boost. 'Rescue teams are really about people,' says Dr Stout.

'They will will be populated with experienced GPs, maybe retiring GPs - to bring experienced oversight and extra staff into the practice to ease pressure. It could also provide an experienced practice manager to go in and look at the organisation, and nurses as well.'

GP retention

The scheme is particularly keen to attract retiring GPs to avoid poaching younger doctors who may take on work as partners, salaried GPs or locums at practices. 'When an older GP retires, the fear is losing 100% of them - if we can keep even 50% that is a huge gain,' the Northern Ireland GPC chair says.

Developing multidisciplinary teams is also a huge part of the way forward, he believes. Plans to extend successful schemes that have seen pharmacists supporting practices are close to roll-out, and will be followed by plans to improve access to mental health workers, physios and nurses with extended roles around practices.

Plans for community-based elective care centres, which will 'dissociate elective care work from acute work' in hospitals, could take effect from 2020 and 'will have a big influence on primary care' by reducing waits and workload, Dr Stout says.

The Belfast GP starts a three-year term as chair of GPC Northern Ireland on Wednesday, and could stay on until 2024 if re-elected. He's clear about the challenge ahead: 'In the broadest possible sense, we know delivery of healthcare has to change across the UK and the western world - driven by demographic pressure, the ageing population and increasing complexity. Pri care has to be front and centre, because we have to extend out-of-hospital care.

'To do that, we need to sustain existing practices, and develop practices to be in a position to take forward a new way of delivering health. With the pressures on the NHS at the moment, if we don’t, the risk is the whole NHS will continue to struggle.'

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