The Doctor Won't See You Now Spotlight

Our GPs say they're facing burn-out.

I've gone to a practice where I sent the doctor home,

where a doctor could barely finish a sentence.

Overworked and underresourced,

they say stress is driving doctors away and is killing off recruitment.

I think it's very, very hard to justify recommending anybody

to be any sort of doctor in the NHS at the moment.

GPs say the crisis is forcing them to think about leaving the NHS.

If I want to continue doing what I do,

it may ultimately have to be outside the NHS.

But I know that it's not what I want for my patients.

With a surge of practice closures already under way,

doctors say it may be too late

to the save the ailing front-line health service.

So, is general practice on its death bed?

Yes, I believe it's on life support.

Belfast in late January.

GPS from all over Northern Ireland

have gathered for a special conference.

They're here to debate an important but difficult question,

and for them, it's crunch time.

We need to make a decision today on undated resignations,

and by that I mean leaving the National Health Service

in Northern Ireland.

GPS in Northern Ireland say they're facing

a crisis caused by years of government neglect

that has made general practice toxic and dangerous.

We have...

the smallest workforce, the highest workload

and the lowest funding of any of the four nations in the United Kingdom.

Daily, we have practices closing, practices collapsing.

Young doctors don't want to be GPs, older doctors are retiring.

The GPs' committee votes unanimously

to sign the undated NHS resignations.

The BMA will now ask every GP practice to sign the letters,

but what could such a controversial move mean?

The service would end up as a fee-led service where people attend

and pay, probably the model not entirely developed,

but something akin to what happens in the Republic of Ireland.

We don't have enough GPs trained.

We may not be able to provide a safe service within the NHS,

moving forward.

So effectively you may become a private health service.

Indeed, that is a very real and distinct possibility.

Away from the conference, Dr Ursula Brennan,

a GP in South Belfast, allows us to shadow her.

'A working day starts anywhere between

'seven and eight o'clock in the morning.

'I have two very small children, one at a year old

'and a three-and-a-half-year-old who's in nursery.'

She arrives at work around 8:30.

-This is up next this morning.

-Yes.

-And there's visits arranged for today.

-Yes.

On a typical day,

she will see 15 patients before morning surgery ends at 11:30.

Basically, here, behind the kneecap?

She has ten minutes to see each patient

and complete any necessary paperwork.

She agrees to keep a video diary,

which shows how her work begins to build from the moment she starts.

'Hi. This is just a normal day in general practice.'

I'm just about to start within the next kind of 10 or 15 minutes.

Just looking at the screens, it looks like a pretty standard day.

I've got a full surgery. I think everybody's fully booked.

Not much capacity for any extras at the minute, but we'll manage.

Aside from the paperwork relating to her own patients,

Dr Brennan shares with her GP partners

the daily telephone calls list.

I think it's about 40 prescriptions that require action now

before the patients are going to be collecting them through the day.

Hospital letters, I think we're amounting about 10 or 15.

Telephone calls, I think we're not too bad at the minute.

We're probably running between... about 30 to be done.

And I don't think there's any home visits in yet,

but, really, just in the time that I've been talking,

there may be one on.

So, listen, I will catch up with you in a wee minute.

When we next see her, 30 minutes later,

she's already under a bit of time pressure.

I've seen the first couple of patients this morning,

and it's difficult to keep to time,

because people come with more than one problem.

Every patient requires different actions

that eat into Dr Brennan's limited time schedule.

One phone call for a drug change for a patient

can result in several phone calls

in terms of linking in with district nursing,

linking in with the community diabetes specialist team...

GPs say their workload has increased by 76% in the past 12 years.

That all began with the signing of a new NHS contract in 2004.

And even though GPs no longer had to do out-of-hours or weekend work,

they took on a big workload from hospitals -

the management of chronic diseases, like heart disease and diabetes.

When we set out, it was controlling diseases that people had.

Now it's more chronic-disease management, so a lot of the work

that used to be done in hospitals has moved towards general practice.

All this extra work represents a major increase in GP consultations.

They've risen by 63% since 2004,

underlining the vital role of GPs as the first point of contact

for patients in the health service system.

-NEWSREEL:

-'This leaflet is coming through your letterbox one day soon.

-'Or maybe you've already had it.'

-When founded in 1948,

the NHS put GPs at the front line of the health service.

'The doctor in his surgery, the doctor in your home, will be free.'

The National Health Service promised free health care

for everyone and assured patients it would relieve money worries

in times of illness.

'Choose your doctor now. That's most important.'

In 1948, a GP's job was much sought after, a prestigious post.

By contrast, today doctors shun general practice.

But why is that?

The BMA say the GP workload is a key discouragement to young doctors.

Taking on what once was hospital work, they added bureaucracy and

the complexities of treating the ageing patient population.

It's more attractive to young doctors to go into

consultancy work or become locums with regular hours and without

the financial responsibilities associated with running a practice.

In Northern Ireland, the average GP patient list is 1,641,

the highest in the UK.

Growing patient lists add to the pressures on GPs to manage

the complexities of more chronic illnesses,

and all against the clock.

In practices, you've doctors seeing 35 patients a day,

writing 178 scrips per day,

doing 35 results, 35 hospital discharge letters,

and that's the average day.

What I just described was the average day for a GP.

Does anyone think that that's a safe level of work?

It's too much work crammed into too short a period of time.

And Tom Black says he witnessed first-hand

the consequences of an excessive workload

leaving a doctor at the point of physical and mental exhaustion.

I've gone to a practice where I sent a doctor home,

where a doctor could barely finish a sentence...

trying to cope with a workload where the doctor hadn't slept for days.

That's not a job that we want our profession doing,

it's not a service that we want our community relying on.

Good afternoon, doctors' surgery.

The BMA says that the demands of the workload

can put intense pressure on individual GPs.

That means when there are exceptional circumstances,

such as the departure of a doctor,

it does not take a great deal to put individual practices

into a state of crisis.

Efforts to stop the closure of a GP practice in Portadown have failed.

When first one then two and three of the four doctors in the

Bannview practice in Portadown left, no replacements could be found.

The sole remaining doctor found herself trying to cope

with 5,200 patients. It was too much.

In the end, the health trust took over the practice.

Dr Shauna Heanan was the last doctor in Bannview.

In her letter of resignation,

she gave an emotional account of her final hours in the practice.

On the day when I had to admit that I couldn't cope any more,

I had done 40 to 50 phone calls to patients,

two overfull surgeries which kept growing in number as more

patients phoned, three house calls, 200 acute scrips,

150 blood results.

I left work in tears that day.

I hadn't slept in four to five days,

couldn't remember the last time I could eat a proper meal

and couldn't concentrate.

A GP at another Portadown practice knows first-hand

about the pressures of being the sole practitioner.

He struggled to cope and came close to walking away.

The main reason was that, you know, I just could not get

any time away from the practice.

I was just about coping with the 12-14-hour days,

but when you cannot get any annual leave at all,

it just becomes completely unsustainable,

it becomes unsafe from a clinical point of view,

it becomes unhealthy from a personal point of view

and it significantly disrupts family life.

He says the pressure left him a broken man with a broken practice.

And the final straw came in October 2015,

when he made a concerted effort to plan ahead

for a few days off in 2016.

Myself and my practice manager, we sent out a total of 2,000 e-mails

and texts to see if we could find any sort of locums who were

prepared to work in my practice to give me some time off.

And those 2,000 contacts resulted in one day.

September 5th 2016 was the only day.

Did that shock you?

That was one of the final straws that said,

"Right, I can no longer go on like this."

Whatever the pressures today on single-handed GPs,

it's worth remembering that for a long time sole practitioners were

a significant part of the bedrock of the National Health Service.

I'm heading up the Antrim coast to meet a doctor

who's lived that utopian dream.

Ben Glover is 78. He should have retired 18 years ago.

Instead, he holds open surgery three times a day.

I think when I came here the oldest patient had been born in 1888,

so I've covered from 1888 up until the present!

When Ben Glover qualified, he was determined to become a GP,

but was told he would have to wait for a practice.

There were 65 in my year when I qualified,

and I think over 30 of them went to America or Canada.

And it was quite difficult then to get a practice.

I was told by an older GP, "Start applying now, sonny,

"because you'll not get a practice for about ten years."

But within two years, he found himself in the picturesque

surroundings of Glenarm.

It was 1966, and he found life as a GP was not too stressful.

We had a motorboat, and we'd go out fishing,

lobster fishing and stuff like that,

but if there was any emergency call come in,

my wife would hang a towel outside the window at the front of

the house and we'd know we had to come in and see somebody.

Even at times of acute demand he managed on his own,

as he did in administering emergency polio inoculations in 1977.

Well, I was given 500 doses this morning,

and we'll continue until they're all used up.

Ben Glover retires in just over two weeks.

His 2,000 patients know just how lucky they've been.

Most of them will now move to a new practice in Carnlough.

We know a lot of the surgeries you have to put an

appointment through, you're talking about maybe ten days to

a fortnight before you get an appointment.

So you could be dead by that time.

There's a lot of people in the village would be elderly who

have no transport, and they would be primarily with Dr Glover,

with no means of travel.

So why not just replace him rather than move his patients?

The answer is you just can't get anyone.

The local trust even tried using the blockbusting TV series

Game Of Thrones to attract doctors to the practice,

but that, too, failed.

Well, it's nothing to do with where it is,

it's the fact that there's no doctors.

Unfortunately, they haven't trained enough GPs over the years.

They need at least 120 GP trainees a year,

and they've only been training 60 here.

In the past ten years, GP practices have continually declined

whilst patient numbers have steadily increased.

The BMA anticipates the closure of another 20 practices next year,

so the pressure is on to train more GPs.

They are struggling to get

the numbers of people to join general practice.

I think, for example, they have about 111 places and they've

struggled to get 111 places on the GP training scheme.

We've created a problem that, within the medical profession,

being a GP is no longer the high-status person.

It's not even middle-status in the whole spectrum

of medical professional people.

Are you saying that we've created

a two-tier system within practitioners?

I think there is a problem of young people graduating as doctors

then deciding which way they go in the health service,

and for the moment, my understanding from the outside

is you're more likely to be incentivised

to go towards hospital work and being a consultant

than you are to becoming a GP.

Yet it's the GPs that are the bread and butter, as they would say,

the bread and butter of the system.

In Northern Ireland at present,

there are over 1,700 doctors in various stages of training.

Only 245 of them are taking the general practice course.

And at the end of training, there's no guarantee that any of

those doctors will become GPs.

We wanted a chance to speak to some of those training to

be doctors in Northern Ireland.

We came to the medical school at Queen's University in Belfast.

We were introduced to a small group of fourth-year students.

You can tell a lot by taking a patient's heart rate,

-taking a patient's pulse.

-That is true, yeah.

Emer Gates says Queen's University

should start their main GP training sooner.

There have been increasing placements

in general practice in final year,

but I think, really, general practice we should be seeing

at an earlier stage, just so that it sets the precedent, really,

for what we're interested in.

We got the provis', obviously, to shadow a GP for three weeks.

The experience was great. I loved it, learnt a lot of new things.

But it's just not a career for me.

The problem of recruiting GPs is exacerbated by the fact

that not only are we not attracting young doctors into general practice

but those already in it, as we've seen with Dr Glover,

are getting older.

In fact, a quarter of the current GP workforce in Northern Ireland

are aged 55 and over,

and that means the loss of around 300 doctors in the next five years.

Nowhere is the problem of an ageing workforce

putting general practice at risk more acute than in Fermanagh,

where four recent retirements have led to practices closing.

And GPs there believe there's more to come.

The doctors say with the number of practices likely to be cut

from 18 to just 5, our largest county is already struggling to cope

with patient needs, and the GPs are left wondering

what the future holds.

I think that, of the 18 practices that we would have had last year,

we'd probably end up with five across three sites.

That's what the GPs in that area tell me,

that they won't have the workforce to sustain anything other

than general practice in three towns.

We will see patients having to travel to see their GP.

They could be travelling 20, 30, 40 miles in some cases.

According to figures from the Department of Health,

the planned closure of four Fermanagh practices

has the potential to displace nearly 8,000 patients.

Nearby practices are on full alert,

concerned about how many of those patients

they might be asked to absorb.

Dr John Porteous is one of five GP partners

in the Maple Practice in Lisnaskea.

They're worried a knock-on effect

could put their own practice at risk.

Effectively, you know, if one practice closes,

there's pressure on the neighbouring practices,

a domino effect, as you've heard it called.

And our concern is, as a practice in the middle of all of this,

that it would put our own viability at risk,

and we obviously can't afford for that to happen.

For the moment, they say they can manage cover in one of the

recently closed practices in Rosslea.

If we go down, then that's south-east Fermanagh

in very, very serious bother.

And is that a dangerous situation?

I think it's a catastrophic situation.

I think we're seeing the outworkings of that now.

They do need to waken up and smell the coffee and get on with it now.

We need to rectify that situation as soon as possible.

This view is shared by Dr Michael Smyth,

who retired last December,

closing his practice in Maguires Bridge.

They would have checked in here at reception.

I felt that, in an increasingly dysfunctional system,

it was becoming both dangerous

and more difficult to deliver good-quality care.

Dr Smyth is saddened and shocked that GPs feel

they have been pushed to the verge of quitting the NHS.

So, is general practice on its deathbed?

It's... Yes, I believe it's on life support.

Back in Lisnaskea,

practice manager Maria Nugent-Murphy has been involved

in detailed talks with local health authorities

about amalgamating with other practices

to ensure the survival of general practice in the area.

I would say we are at capacity, definitely, at the minute.

We were getting quite scared about what was happening around us,

especially when advertisements went out

and no replacements were being found.

But it's stretching you a bit further than you want to go.

Yes, it is, definitely, yes.

Really, we see a more sustainable solution

as being in one centre, one hub.

And that's really where we feel things need to go

to be sustainable in the long term.

That's something John Compton agrees with.

He says GPs need to change the way they work.

Well, I think the sort of changes,

for example, issues where there are partners in the practice

who are advanced nurses or pharmacists, they have to think

about what they're being asked to do differently.

They have to look at how they work.

Are small, single-handed or two-handed practices

really the way forward when you think of the next ten years?

And I think those sort of challenges are there,

and that does mean some amalgamations of general practices,

it does mean general practices working in much broader networks.

So you're talking about some kind of a hub.

I think so, yes. Hubs, of course, are the way forward,

but hubs are no use if it's just simply the restatement

of five traditional practices into a building

and nobody does anything to change how you operate in that building.

That's been the solution for Dr MacDonald,

who's merged his practice with three partners

inside the hub at Portadown Health Centre.

The clinical burden is pretty much the same, and that's fine.

I can share the administrative burden.

I find that now we can hopefully cover holidays between ourselves.

What's been happening with you since I last saw you?

Nevertheless, even hubs can mean a heavy workload,

as we see back in Belfast with Dr Brennan,

who has three GP partners.

I've seen a very complex mix of patients this morning,

some patients with multiple problems.

I'm just going to go back. I have a couple of patients waiting for me.

Half an hour later, and Dr Brennan has seen her last patient

but has more still to do.

I've just finished my surgery.

Running probably about 20, 25 minutes late,

which is just an ordinary day.

I think there's probably about 10, 15 people still looking for me

this morning who need me to call them back.

And I think there's two or three home visits, which we will, erm,

need to do over lunchtime.

I talked to Dr Brennan after her busy morning surgery.

I'm on my half-day off.

I'm going to be doing more work this afternoon, as well.

And then my day doesn't stop there.

So, when I get the children to bed, so around eight o'clock,

I'll dial in again to try and do some preparatory work for tomorrow.

I think that many of us are coping at the moment

and we're continuing to provide a really safe service,

but if there is something unforeseen, I think that...

you know, we've talked, and the word has been used, about domino effect.

Very quickly, practices can become in crisis, actively in crisis.

-If they come into difficulties...

-PHONE RINGS

..it will have an impact on adjoining practices, so...

I'm sorry, I'm going to have to take that.

-Yes, of course.

-Sorry.

Hiya.

GPs may have good lines of communication with their

patients, but when it comes to the Government, they feel sidelined.

And the BMA says the turnover of health ministers,

four in the past three years, has had an adverse impact

on making decisions on the future of general practice.

It's very frustrating,

because you form a relationship with the minister, you have a plan,

you have a way forward, and the next thing, they're gone.

And the last two ministers have had, what,

less than a year each in post.

In fact, the last three, probably,

have all had less than a year each in post.

And it is very frustrating.

During the life of the Stormont Assembly,

there have been a series of reports on the health service.

The most recent was published in October last year.

The reality is that the current model is unsustainable.

It was chaired by Professor Rafael Bengoa,

an internationally renowned expert on health reform

who has previously advised the European Union

and the Obama administration.

In his report,

Professor Bengoa acknowledged that there should be more GPs trained

and that GP practices should have a dedicated support team,

a named social worker, health visitor and district nurse

to alleviate the workload on doctors.

It was seen as a positive step

towards fixing the problems in the health service

and enjoyed the full support of the then Executive.

I'm delighted that the Executive has endorsed a direction of travel

for how we're going to transform health and social care.

We had a very clear choice to make.

We either try and manage the change

or we either manage the chaos that would come

if we didn't tackle the huge issues that there are.

The entire Executive have bought into this ten-year strategy.

But, as we know, within a few months the Executive collapsed,

and that unity of political purpose

over the way ahead for our health service has stalled.

It's absolutely critical that we now get ourselves an Executive,

the Executive publicly recommits to the Bengoa report

with the First, the Deputy First Minister and the Health Minister all

standing, if you like, firmly, saying,

"This is what we're going to do",

because without that, you lose the support of professionals.

They become disappointed and disillusioned.

We've reached a point in Northern Ireland where something

has to be done. If we as GPs have to leave the NHS to fix this, we will.

At the moment, the NHS is toxic to general practice.

But is the threat to leave the NHS a realistic one,

or is it simply being used as a bargaining tool?

For some members of the public,

the idea of having to pay for treatment has already taken hold.

I had a consultation recently where a patient came to see me

and she assumed that it had already happened and that we were charging,

and she reached down at the end of the consultation to give me money.

And I just became really quite upset,

because it's not what I signed up to do.

It's not just about tactics or about playing a game,

it's a profound statement about where our NHS is going.

I want people to pay attention to that,

and I want people to understand they have workforce issues,

they have training issues, they have new-models-of-care issues,

and they want a solid understanding from government

and a commitment from government to effect a change into the future.

Few GPs want to leave the NHS,

but some have become extremely pessimistic about its future.

I think it's very, very hard to justify recommending anybody

to be any sort of doctor in the NHS at the moment.

And I don't take any pleasure from saying that.

That's just the cold facts.

The BMA has been casting an envious eye

towards England and Scotland, where GP budgets have been boosted.

The most recent, an increase of £71 million,

was announced in Scotland last Friday.

Here, the Department of Health says it recognises

there's more to be done to improve GP services,

but without a health minister or an Assembly,

GPs are left wondering when that help is going to come.