The NHS was introduced in 1948 by the then British minister for health Aneurin Bevin and delivered free healthcare for all at the point of delivery. Much has changed over the years; once lauded as the best health system in the world, comparative to peer countries, it has dropped considerably down that league ladder and is not the shiny jewel it once was.
A report from the King’s Fund in 2023 showed the UK to be lagging behind in many key areas, including fewer hospital beds, doctors and nurses per 1,000 patients; lower numbers of CT and MRI scanners; and worse outcomes for treatable cancers, as well as in strokes and heart attacks. This has largely been the result of 14 years of a Conservative government whose policy choices and overall disinvestment have brought the NHS to its knees, and public satisfaction in it to an all-time low of 24 per cent.
While the NHS as a whole in the UK falls down the world league of health systems, here in the North we find ourselves in a league of our own and it isn’t a very good one. On almost every measure our healthcare system performs worse than its counterparts in England, Scotland and Wales.
This is probably seen most starkly in our waiting lists. At the start of last month the latest statistics showed that there were more than half a million people waiting to see a hospital specialist. That is one in four of the population. The cost of addressing this is reckoned to be in the region of £1 billion (€1.2 billion). It is a startling figure, particularly when you consider that nothing of that will be invested into preventing us from ending up in the same position again if and when this backlog has been cleared.
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So what does all of this mean to someone like myself, a GP partner of more than 25 years’ experience, who works in a deprived area in Belfast right next to the Royal Victoria Hospital?
When I first took the practice on as a single-hander in 2002 I had 1,700 patients. That figure has risen, along with the workload, to 3,200. This is in keeping with the overall rise in practice list sizes regionally alongside a reduction in GP practice numbers from 350 10 years ago to 312 in March of this year, and a worrying flatlining in the number of GPs, with those who are partners trending down.
The North’s population has also increased in this time by almost 7 per cent, to just over two million. As in the South, our demographic has also hugely changed to one that is much more ethnically diverse. There is not a day that goes past now when I am not using interpreters, which was a rarity even five years ago. It is often interesting to see the look of incredulity on patients’ faces when I outline just how long it might be before they get to see a hospital specialist here, particularly when their developing country of origin offered much better access to equivalent secondary healthcare.
With the current woeful state of waiting lists, we on the front line see the impact back in our practices.
GPs in Northern Ireland currently see around 200,000 contacts per week. Many of these will, of course, be from the one in four who will be waiting for hospital care of some description. With the wait, conditions inevitably deteriorate. The current waiting time to see an orthopaedic surgeon is up to five years and if they agree to do an operation, it will take up to another five years to get it. To see a rheumatologist, routinely it is around eight years.
Unsurprisingly these patients come back to the GP over and over again, for changes to their pain management or simply to find out what is happening to their appointment which, of course, we don’t know.
In 2023 the Ombudsman published its report Forgotten – a Report into Healthcare Waiting List Communications, the title of which reflected the feeling of 88 per cent of those on a waiting list. It made many recommendations on change, but the pace of any of them being implemented feels very slow, at least from my perspective.
The one area that is burgeoning is private healthcare. You only have to take a drive around the affluent Belfast area of BT9 to see that in action, with an increase in the number of shiny new buildings offering timely, paid access to services. Kingsbridge Private Healthcare’s profits rose from £76.9 million (€93 million) in 2023 to £137 million (€165 million) in 2024.
Undoubtedly this expansion has attracted staff from the NHS, putting more pressure on a service which already has significant recruitment issues. We are also seeing an increase in private general practice, which was unheard of even five years ago. Even working in an area of significant deprivation, I am seeing an increasing number of people asking for a private referral, people who can little afford it and are turning to credit or their meagre life savings to pay for it.
Patients in the North will consult their GP around six to seven times per year, compared to three to four in the South where the outcomes are now better, alongside life expectancy and quality years lived. For this, practices are reimbursed around £115 (€139) per patient. A colleague of mine worked out that this was less than you would pay annually for insuring a hamster.
A report from the Northern Ireland Audit Office in March on GP access showed that only 5.4 per cent of the overall health budget was being spent on general practice and almost one in three practices had sought crisis support services (set up by GPs themselves} in the last four years, such are the current pressures.
Another figure to come out of this report was around the stalled project that is multidisciplinary teams: only around 8 per cent of the population have access to one. My own patients are fortunate enough to be in that cohort and it has made a significant difference to my workload. The team includes a pharmacist, a physiotherapist, a mental-health practitioner, a social worker and an advanced nurse practitioner. Investing in this would almost certainly make significant strides in stabilising practices and reduce the likelihood of more closures.
Our hospital emergency departments (EDs) are not faring much better, with blockages keeping patients waiting too long in departments and in ambulances; these in turn cause delays in emergency responses. People are dying as a result.
“Exit block” from the hospital is one of the main contributing factors: significant numbers of people who are fit for discharge are unable to get home because of a lack of suitable care packages, again showing the lack of investment into care in the community or alternatives to ED treatment.
The number of people who get fed up waiting and leave before their treatment is finished is also worryingly on the increase, standing at around 7 per cent. Many of these will end up contacting their GP, often for results of investigations that they had initiated but did not stay to hear the outcome of. Some of these will be significant and potentially life threatening.
What we don’t have figures for are the numbers of people who will be avoiding or delaying attending the emergency department in the first instance but anecdotally this is also on the increase, again impacting on potential outcomes.
So how can we make things better? For a start, this comes from strong leadership and being able to have the honest conversation with our population about what the money they have can realistically buy now. It will mean implementing the recommendations of the seven health reviews we have had to date, all of which pointed to the same areas of reform including reducing the number of acute hospitals we have.
It will require unity of purpose across the Northern Ireland Executive whose track record on delivery has not been great.
Minister for Health Mike Nesbitt has just published his three-year strategic plan, part of which is around stabilising the health service. What isn’t clear is whether this will be enough to actually deliver on it. Right now the grass is looking a little greener down the road.
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