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North and South: The general practice dilemma 

By Priscilla Lynch - 30th Mar 2024

North and South

Northern Ireland’s health service is in crisis and many of its GPs are leaving to work in the Republic.
Priscilla Lynch reports

Irish doctors and healthcare staff remain in high demand across the world. The UK, and in particular Northern Ireland, has always been an attractive destination, especially for those in the border counties, with the NHS long being held up as the ideal to aspire to for our own health system.

However, in recent years, the medical brain drain to the North has slowed and is now happening in reverse. Health services in Northern Ireland are currently experiencing record-breaking hospital waiting lists and emergency department (ED) pressure (see panel on p6). GP practices are also struggling and shutting their doors. The suspension of Stormont for two years, and associated stalled budget and policy issues, including the impact of Brexit, have all contributed to the deteriorating situation.

The resulting crisis, and lower wages, have seen doctors in the region look to the Republic for work, while our own healthcare staff are no longer crossing over the border in significant numbers.

While there is no official data available to show exactly how many doctors from Northern Ireland or the mainland UK are now working in the Republic, anecdotally the numbers have increased in recent years.

According to the Medical Council’s Medical Workforce Intelligence Report 2021, 692 doctors who obtained their basic medical qualification in the UK retained their registration and reported being clinically active and working in Ireland. This figure increased to 721 in the data for 2022.

The situation has caused alarm among health bodies in the North, including the British Medical Association (BMA) Northern Ireland and the Royal College of GPs Northern Ireland (RCGPNI).

Crisis in general practice

General practice in Northern Ireland is currently experiencing a major crisis, with a surge in GP NHS contract ‘hand-backs’, practice closures and imminent shutdowns. The reasons are varied and include chronic underfunding and debt challenges, as well as increased NHS bureaucracy and patient demand, according to Dr Tom Black, BMA Northern Ireland Council Chair.

Dr Tom Black

Dr Black, who has been a GP in the Bogside area of Derry for 35 years, said the situation in general practice is extremely difficult for all GPs presently in the North. Not only are younger GPs looking to the Republic, but long-established principal GPs are also moving or considering relocation, he told the Medical Independent (MI).

His own practice has recently launched a hybrid public-private model where it sees private patients at £75 an appointment. The decision was made in an attempt to stay financially afloat. These patients are not registered with his practice for public services as that would be in breach of the NHS contract. The controversial move has garnered significant publicity in the North, where it is seen by some as “the beginning of the end of the NHS”.

Dr Black said he felt he did not have a choice as his practice had been losing money for over a year, had a significant overdraft, and was struggling to retain staff. He explained the private fee is not for the GPs themselves, but goes back into the practice to help pay more competitive wages and settle the bills. Dr Black believes other GP practices in Northern Ireland will follow suit with similar models.

Financial issues aside, Dr Black said it is very difficult for GPs in Northern Ireland to cope with their current workload and to witness the struggles their patients face in accessing any type of healthcare.

“It’s truly awful…. My patients can’t get operations done, they can’t get outpatients done, or inpatients done,” he said.

“So they see their GP frequently and they end up on higher doses of medication, particularly pain medication. We have lots of patients on morphine patches and I’ve never had so many people on morphine syringe drivers.”

Dr Black noted that his practice has over 7,000 patients in an area of high deprivation.

“It is very difficult to see your GP [in Northern Ireland] as they are very busy and working harder than ever, and it is very difficult to get an ambulance. Sometimes we get quoted figures of seven hours for an emergency ambulance. It is very difficult to be seen in an ED as they’re so busy. Patients can be waiting 27 hours to be seen. They could then be waiting a couple of days to be admitted to a ward bed. The patient journey is horrendous,” Dr Black told MI.

He added that some of his older and sicker patients would “rather take their chances and die at home than go to hospital”.

“People in the Republic don’t appreciate how good their health service is. The waiting lists are much shorter. We are 11 times higher for the most significant cases.”

Decline

Official data reveals a stark decline in the number of active GP practices in the North. According to the Department of Health in Northern Ireland, they went from 350 in 2014 to 317 as of 31 March 2023, a reduction of over 9 per cent. The numbers have declined further since, according to the Department. In the last two years alone, there have been 22 GP practice contract hand-backs.

Concurrently, the average number of registered patients per practice has surged by approximately 17 per cent, escalating from 5,500 to 6,439 to the end of March 2023. Overall, there were over two million patients registered with a GP practice in Northen Ireland this time last year.


Dr Alan Stout

Extreme pressures on GP services have resulted in locum doctors being paid up to £1,000-a-day to work in practices run by Health and Social Care Trusts after contract hand-backs, a new Northern Ireland Audit Office report has found.

The report from Auditor General Ms Dorinnia Carville said that 98 GP practices (almost one-in-three) in the region have sought crisis support services in the last four years.

The report also highlighted GP recruitment and retention issues. While the total number of GPs in Northern Ireland increased by around 9 per cent between 2018 and 2023, the report cautioned that changing patterns of GP work practices and an increasing population mean there has been an overall decrease in whole-time equivalents. “While GP numbers may be rising, it is likely that fewer GP sessions are being delivered.”

The report also highlighted the slow progress in the roll-out of multi-disciplinary teams (MDTs) in the North. MDTs were launched in September 2018, with a planned incremental roll-out over five years. However, the report said that by March 2023, MDTs had been fully introduced in only one of the 17 GP Federation areas across the North and partly introduced in seven areas.

Only around 161,000 (8 per cent) of registered patients currently have access to the full range of MDT roles. The report said a lack of available, qualified staff was a key constraint.

Dr Alan Stout, Chair of the BMA Northern Ireland GP committee, said there has been a particular upsurge in GP practices relinquishing their contracts in the last 18 months due to financial struggles. Dr Stout believes the current number of GP practices has fallen below 310 in the region and described the quantity of contract hand-backs as “significant”.

“The amount of funding coming into practices just doesn’t meet needs at the moment, in terms of paying staff and paying bills to keep practices a viable entity,” he told MI.

“We also don’t have enough GPs,” he said. “We’ve had a slow MDT roll-out and then the workload is just through the roof. We have a growing population with a huge increase in patients since 2014, which really aren’t accounted for in the funding, as well as increased pressure from an ageing population.”

GPs in Northern Ireland do not have a State-backed indemnity scheme like in England and Wales, which is also a source of contention.


It’s truly awful…. My patients can’t get operations done, they can’t get outpatients done,
or inpatients done

Why is the Republic now more attractive?

While it has always been very common for doctors to cross the border for work, the Republic is currently seen as particularly attractive for GPs in the North.

Speaking to MI, Dr Ursula Mason, Chair of the RCGPNI, said there are a variety of reasons why GPs from Northern Ireland may be deciding to work in the Republic. 


Dr Ursula Mason

“It is clear that the current climate of underfunding and resultant financial instability coupled with increasing demand and not enough GPs is driving increasing attrition to all parts of these islands and indeed further afield,” Dr Mason said.

She explained that general practice in the North does not currently offer the same career opportunities and work/life balance as the South.

“Many of our GPs cite not just better terms and conditions as a driver to relocate, some of them tell us that working in [the Republic] affords them the opportunity to deliver better care for their patients.”

Dr Mason said that more and more GPs in the North are “suffering moral injury” through not being able to support patients in a system that cannot effectively meet their health needs.

“Sending a ‘red-flag’ referral for a patient in whom cancer is suspected, in the knowledge that it may be months before diagnosis let alone treatment, knowing that the patient in front of them cannot afford to ‘go private’, or being the only point of contact month after month for a patient languishing on a hospital waiting list that is more than five years long, all takes its toll on hard-working GPs who simply want to be able to do their job and do it well.”

She added: “We have an increasingly diverse and mobile GP workforce, particularly at the early career stage and the challenges in recruiting and retaining are not isolated on this island. Northern Ireland must become an attractive place to live and work for a future generation of GPs and their families. That can only happen by redressing the funding shortfalls, stabilising practices, and retaining the current workforce – only then will Northern Ireland be able to attract, recruit, and retain a workforce that is fit for the future.”

Mainland UK doctors also making the move

It is not only Northern Ireland that is experiencing GPs moving to the Republic. Doctors from other parts of the UK are also beginning to see Irish general practice as a more attractive option than the NHS.

In recent years GP Dr Eamonn Jessup left his partnership at a surgery in Prestatyn, north Wales, where he had been based for 30 years. Dr Jessup made the move for a number of reasons. These include  punitive pension rules for GPs (which have recently been amended), increasing workloads, and NHS bureaucratic issues.


Dr Eamonn Jessup

Dr Jessup worked in different parts of Ireland as a locum initially. He settled in north Kerry a couple of years ago, where he currently works for a GP practice in Listowel. Now in his late 60s, Dr Jessop told the Medical Independent that he enjoys the pace of life and approach to primary care in rural Ireland.

“All I want to do is make patients’ lives better. That is what doctors should do,” he said. Dr Jessup added that he felt he was unable to practise this way anymore under the NHS model in Wales.

“Here I can take a foreign body out of an eye, stitch them up. Over there they look at you and say ‘why didn’t you send them to casualty?’. I enjoy doing what I can to the limits of my competency. I don’t want to be sending everything from an ingrown toenail off to see a consultant. It just struck me as becoming increasing inefficient [in the NHS system] and just a referral service.”

He acknowledged that the system in Ireland is not perfect.

“In many ways it’s chaotic,” Dr Jessup said.

“But it is a better fit for me, for what I want to do for patients.”

On the ground

Dr Paul Armstrong, a recently retired GP who worked near the border for 35 years in Lifford, Co Donegal, told MI he has watched with interest as the medical brain drain from Ireland to the NHS has reversed in recent years.


Dr Paul Armstrong

“Being based on the border, it was always the other way,” Dr Armstrong said.

“Huge numbers of people from the South went to work in the North or the UK because the system was considered more stable, partnerships were more transparent, pensions were reasonable, the NHS was working well…. But that has stopped and reversed somewhat.

“In Donegal we would have principal GPs who moved from practices from Derry into GMS lists in Donegal. That is definitely new. The other group is those GPs coming out of their training schemes and choosing Donegal rather than the border counties to work in. We would have a lot of people who actually live in the North, but choose to work in the South, which is a reverse to what was there 30 years ago.”

Dr Armstrong said while the demands in primary care in Ireland remain significant, there have been improvements in the last decade. These include increased funding and a reversal of the FEMPI cuts, as well as strong GP training programmes.


People in the Republic don’t appreciate how good their health service is

“To be fair, the State has put in a lot of resources trying to sort out waiting lists, trying to sort out chronic disease management, sort out our social services and home help. So as bad and all as some of us think it is, it is not that bad in comparison [to the North], and that is what we are seeing on the ground now.”

He added that situation is being mirrored in patient migration trends.

“And the other cohort who know this are the patients. In border areas we would have a lot of patients with dual eligibility, working and or living on either side of the border, who were registered with us who would have access to the health service on both sides. Going back 30 years ago if they wanted to go to [emergency departments] or have a baby we would chat about where they wanted to go and 80-to-90 per cent of the time they would have gone North. That has been reversed. Now they go to Letterkenny, which while it has problems, the medical care is very good there. In terms of waiting lists, they will go to the South. And that is a transformation.”


Dr Denis McCauley

Fellow Donegal GP, and incoming IMO President, Dr Denis McCauley echoed Dr Armstrong’s comments. His practice has a GP partner who was practising in Derry previously.

“Donegal general practice is a relative benefactor of the fact that general practice in Northern Ireland is just collapsing,” Dr McCauley told MI.

Dr McCauley pointed to the unstable political situation in the North and the underfunding of general practice in the UK overall. He also referred to the significant “increase in extra responsibilities” for NHS GPs. Dr McCauley said there seems little hope the situation will improve in the short-term at least and the movement of Northern Ireland GPs to the Republic will continue for the foreseeable future.

“There are workloads which are just excessive,” he said.

“It seems to be triaging by the seat of your pants all of the time. And it is just very, very difficult. I think Covid compounded the problem. But really it is general practice being asked to do too much and given too little.”

Making the move

Donegal GP Dr Peter O’Boyle graduated from University College London in 2000, and completed his general practice training in Northern Ireland. Having worked as a GP in Derry since 2011 he joined Millbrae Surgery in Stranorlar, Co Donegal, in 2022. So what prompted the move?

“Brexit was the main driver for me personally,” Dr O’Boyle told MI.

“When it came it made me think about the whole situation again. I was living in Donegal, working in Derry and suddenly my take home pay dropped by about 25 per cent because of Brexit and the crash in sterling. It never recovered really to what it was before Brexit.”


Dr Peter O’Boyle

Like other Northern Ireland and NHS GPs who spoke to this newspaper, Dr O’Boyle said the NHS GP system has become very bureaucratic and “about box ticking”. He also referred to waiting lists, an unstable political system and health budget issues. Dr O’Boyle said he is happy to have made the move to the Republic and has settled in well.

The ICGP has also noted the trend. Dr Diarmuid Quinlan, Medical Director of the ICGP, said: “While we have no specific data on the number of GPs moving from Northern Ireland to work in the Republic, we are aware that there are GPs moving from the NHS in Northern Ireland to work here, particularly in the border counties.”

With a significant shortage of GPs in the Republic and growing patient demand, the influx of GPs from across the border is welcome, Dr Quinlan acknowledged. “We welcome experienced and qualified GPs who wish to work in practices here from anywhere in the world. We are also currently recruiting experienced GPs to the ICGP international medical graduate rural programme. We know that many GPs, currently in Canada and the US, have studied in Ireland and might consider returning to Ireland. Ireland is an English-speaking, safe, stable, liberal, Western democracy. The Republic is an attractive place to work as a GP, with flexible working options, good career prospects and strong financial incentives.”


… I think Covid compounded the problem. But really it is general practice being asked to do too much and given too little

Northern Ireland – a health service in crisis

British Medical Association (BMA) Northern Ireland Council Chair, and GP in Derry, Dr Tom Black said the current state of the health service in the North is the worst he has seen in his 38 years in medicine.

“Things have become much worse in Northern Ireland. We have huge problems with access to GP appointments, to ambulances, to emergency departments (EDs), to getting a bed on a ward, to getting into hospitals.

“Our waiting lists have gone up. One-in-three people in Northern Ireland are now on a waiting list for inpatients, outpatients, and diagnostics. That is not a functioning service.”

In a recent keynote speech at a Royal College of GPs Northern Ireland (RCGPNI) event, newly reinstalled Minister for Health Robin Swann acknowledged that the current state of the health service is “deplorable” and “unprecedented”.

“Unprecedented is a word perhaps used too often, but I believe the combination of pressures and demands on the system and very real budget shortfalls mean the health and social care system is in a very difficult and unparalleled situation,” Minister Swann said.

“Responding to this situation will, I believe, also require perhaps unprecedented actions, of course, including efficiency, improved performance, and change, but also a real debate about what we all can expect and receive from our health and social care system.”

He added that the risks of a health service breakdown are real and growing in a range of areas.

 “I do not say this to frighten people, but to help build a shared understanding. We continue to have expectations and demands of health and social care that we cannot currently meet and on the current trajectory the situation is getting worse rather than better.”

On 18 January, nurses, midwives, and healthcare workers, along with other public sector workers, took part in the largest strike in Northern Ireland for 50 years over demands for pay parity with the rest of the UK. Junior doctors then went on strike for the first time ever in the region for 24 hours in early March. This industrial relations action was also taken over pay parity issues.

Dr Fiona Griffin, Chair of the BMA Northern Ireland junior doctors committee, said the strike action went ahead after 97.6 per cent of balloted doctors voted in favour of industrial action for full pay restoration to reverse over 16 years of pay erosion. While newly qualified doctors in Northern Ireland earn £26,000 per year, in England the starting rate is over £33,000, and in Scotland it is £32,000.

“No doctor wants to strike, but we feel we have been left with no choice but to stand up for ourselves. We are no longer going to put up with unacceptable pay and conditions; they are causing an acute workforce crisis that is not being taken seriously,” Dr Griffin said.

The latest hospital waiting list data for Northern Ireland shows a record one-in-three people in the region were waiting for an inpatient or outpatient appointment at the end of December 2023. Many of these people have been waiting years.

The median waiting time for an outpatient appointment was 49.6 weeks and the 95th percentile waiting time was 257.4 weeks. For inpatient procedures, the median waiting time was 58.4 weeks and the 95th percentile was 280.7 weeks (approximately five years and 30 weeks) on 31 December.

These waiting lists are the longest in the UK, and twice as long as those in the Republic. Dr Black denounced the situation as “appalling”, saying that patients can wait over a decade for a joint replacement. He added that long waiting times for urgent referrals are also a concern.

“The biggest problem is ‘reg-flag’ referrals. That is something that needs to be seen within two weeks, ie, a high risk of cancer, and many of those services have very long waiting lists for red-flag referrals and also then for the follow-on investigations that brings them back to oncology, which has very long waits. So the patient journey is constrained at every point. It is not a time to be sick in Northern Ireland. It is not a time to worry that you have cancer and it is not a time to be in pain with a hip or knee or any other problem.”

In relation to ED waiting times, the number of patients who waited more than 12 hours last December increased by 16 times compared to the same timeframe in 2016. This compares to zero patients waiting that long in April 2008. The percentage of patients who left EDs before being treated also reached a record peak of 8.6 per cent in November 2023.

Commenting on the data, Vice-Chair of the Royal College of Emergency Medicine Northern Ireland, Dr Michael Perry, said: “The unsurmountable pressure on emergency departments is proving detrimental to patients and staff, with no respite in sight…. We reiterate our call for the new Health Minister and the Department of Health to #ResuscitateEmergencyCare to adopt our five priorities, with the most urgent focus to increase and maximise functional bed capacity and implement measures to retain our hardworking staff before the UEC [urgency and emergency care sector] implodes.”

Asked whether he thinks the situation will improve in the short-term, Dr Black was not optimistic.

“The dilemma is that not only do we not have the resources to provide the service, but to catch up on the waiting lists. So therefore we are going to have to prioritise the things that we do, and the funding and staff that we have.”

Additional reporting by Paul Mulholland

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