The withdrawal of care

Life at Work
Jennifer Trueland

GP practices are collapsing in Northern Ireland where political leadership on healthcare is lacking owing to the pause in power sharing. In the third instalment of The Doctor's study into the pressures facing family doctors, Jennifer Trueland speaks to a GP under extreme pressure

We’re sitting in Ursula Brennan’s bright and modern room in Mount Oriel Medical Practice in south Belfast and an email pings. It’s confirmation from the Department of Health that yet another GP practice in Northern Ireland has effectively collapsed.

There had been hopes that a contractor would be found to take on Priory-Springhill surgery, but this hasn’t been possible, so instead it was due to be passed over to the South Eastern Health and Social Care Trust.

‘We’ve had 11 list hand-backs since April,’ says Dr Brennan, a GP partner and chair of Eastern local medical committee. ‘And so many other practices are one [GP] resignation away from disaster.’

When one practice hands back its contract, it can be a bit like a set of dominos. If the health board decides to disperse the patients – essentially sharing them out among other practices – this puts an additional strain on all the GPs in a locality. Sometimes it will be enough to precipitate further practice collapses. ‘An extra 300 patients can make the difference between being viable or not viable,’ she says.

Locum demand

There are several GP-led mechanisms to support practices in trouble, including the Northern Ireland-wide Practice Improvement and Crisis Response Team. But too often the help available is just not enough to stave off collapse. A shortage of GPs means locums are like gold dust, further adding to pressures.

Public perceptions that GPs ‘haven’t been working’ over the course of the pandemic don’t help morale, says Dr Brennan, and sections of the media have consistently fanned the flames. ‘There’s a lot of talk of “part-time GPs” and people think we’ve not been working, and we’ve not been seeing people face-to-face,’ says Dr Brennan. ‘But we’ve never been away – and our workload continues to grow.’

Lack of political leadership is adding to the pressure too. The latest collapse of devolution in Northern Ireland means there is no health minister to make vitally needed decisions, and measures that could help – such as a rollout of general practice-based multidisciplinary teams – have stalled.

‘I think our practice is one of the last on the route map to get an MDT [multidisciplinary team], but to be honest it’s a moot point, because we don’t have a health minister, and the civil servants may not be able to divert the necessary funding,’ says Dr Brennan. ‘I can see it being five or 10 years until we get an MDT.’

We’ve never been away – and our workload continues to grow

Dr Brennan

This has an effect on recruitment, she adds. ‘If you were a young GP who wanted to stay in Northern Ireland – which is a diminishing pool – would you want to work in an urban area with a full MDT or would you work in an area without an MDT? If you were smart and savvy you would work where you have as much of the supported primary care team adjacent. It does impact on recruitment – and colleagues who have an MDT say it’s been a game changer.’

As with practices across the UK, Mount Oriel has moved to a system where consultations are initially conducted by telephone, with patients being called in to see a member of the team if required. By 9am, Dr Brennan’s morning surgery is already full and the afternoon ‘emergency’ slots are also filling up.

Dr Brennan’s voice is invariably cheery when she calls the patients, and most sound pleased to hear from her – even when the news isn’t good. Several consultations in the morning merit a referral to secondary care, but there’s no prospect of anyone being seen any time soon, unless they are prepared to pay privately.

‘We’ve got the worst waiting times in Europe,’ says Dr Brennan, scrolling down a list showing waits for the Belfast Trust. These are truly shocking. An ‘urgent’ neurology appointment will be 157 weeks – and you can forget about ‘routine’ because it’s twice as long. Patients will also take several years to get a first appointment for orthopaedics, then wait a similar time to get the actual procedure. It’s a similar picture across the board.

Political failure

Until September, it was possible for patients in Northern Ireland to pay a smaller amount to have a procedure in Ireland as part of a cross-border arrangement. But again, that’s been stopped because there’s no health minister to agree to extend it, adds Dr Brennan.

It’s only lunchtime and she’s looking tired as she grabs the soup she has brought in and eats it at her desk, constantly scrolling the ever-fuller list of work still to do. She had worked at home the previous evening, getting ahead with some of her admin, until one of her two children started coughing at 10pm and she was pulled away from her computer.

While she is very matter-of-fact with her patients about the length of waiting times, and prints out letters of referral for private secondary care consultations in at least three cases in the few hours I was there, it clearly gets to her. She worries, she says, that she is helping to create a two-tier healthcare system, but what else can she do?

GPs are experiencing moral injury, she says, and taking a bashing from the media, and occasionally even from patients, adds to the pain; it’s also difficult to leave work behind when she is supposedly off duty. ‘It’s just not possible for us to do what we want to do for patients,’ she says. ‘And then I go home to small people who look to me to light up their lives.’

In her medical political roles – as well as being LMC chair, she sits on NIGPC and is South Belfast Federation director – she is only too aware of the impact that excessive workload and pressure is having on colleagues. But she is also witnessing this as a medic. ‘It greatly worries me when I am the GP of patients who are young doctors and they have stress ulcers,’ she says. ‘There’s nothing left in the tank.’