Privatisation by the front door: what does a new public-private GP model mean?

The beginning of 2024 marked a watershed moment in the history of the NHS in Northern Ireland, with the opening of the first hybrid public-private GP surgery. Abbey Medical Practice, located in an inner-city area of high deprivation in Derry, began accepting private patients in a bid to stay afloat.

This move has caused quite a stir. Dr Alan Stout, chair of the BMA GP Committee for Northern Ireland, commented that “this is the beginning of the end of the NHS as we know it”. While some reactions applaud an innovative response to getting more money for the NHS, others raise the fear that this move is the beginning of a slippery slope to something like the model for dentistry in the NHS, where staff and patients alike are squeezed into paying for care as the state system withers.

What actually happened?

One of us (Deirdre) spoke to the senior GP partner at the practice, Dr Tom Black, the chair of the BMA’s Northern Ireland branch and a prominent figure for many years. He said he was left with “zero choice in the matter”. He argues that the practice had been losing money for 15 months and faced bankruptcy in six. Under this arrangement private patients, drawn from people outside the practice’s NHS list, are charged at £75 per appointment. The intention is to use that to subsidise the care of NHS patients.

Significantly, this hybrid arrangement is entirely dependent on the goodwill and voluntary effort of the four other partners in the practice. They have agreed to see the private patients without getting any extra payments themselves, so that the extra money can prop up the bottom line of the NHS practice. The partners have guaranteed the same number of appointments will be available for the NHS patients.

A sign of the times

It is not a coincidence that this has happened in Northern Ireland in early 2024. Total spending on Northern Irish general practice dropped by 7% in 2022/23 in real terms, following two years of higher spending to cover specific services at the height of Covid-19.

Freedom of information requests showed that 7% of all GP practices asked to close their lists to new patients in 2022: the Northern Irish department of health introduced a national freeze for the winter of 2022/23. Last November, the Belfast Telegraph reported that 14 practices, close to one in 20, had handed back their contracts so far in 2023.

The long period without a government may have contributed to the apparent lack of progress on a commitment by health minister Robin Swann to look into indemnity costs. GPs in Northern Ireland do not have a state-backed scheme, unlike in England and Wales, which is a source of regular complaint.

The median waiting time for inpatient care in Northern Ireland is over a year from the decision to admit. This is actually a mild improvement from 18 months in 2021. In England, the median wait is just 14 weeks, and this is with a method that starts counting much earlier from the point of GP referral. Hospital backlogs mean that GPs are having to manage people and their deteriorating health for longer.

To a great extent, the underlying pressures are reflected across the UK. The drift from full-time to part-time working has been highlighted as a concern as it has been in England, although there is a lack of data to illustrate this for Northern Ireland. England has actually seen a falling number of GPs for years, and has far fewer per head than Northern Ireland, as does Wales.

A slippery slope?

Whatever the merits and safeguards of the model at the Abbey Medical Practice, it is easy to see why others might see a potentially concerning fundamental shift. The Nuffield Trust recently warned that NHS dentistry in England was an example of a service that was close to being gone for good, and forbiddingly expensive to bring back. This happened because NHS contracts were unable to compete successfully against private fees for dentists’ time. The Republic of Ireland, meanwhile, faces problems expanding the number of people getting free state-funded care because, with a similar workforce squeeze, GP lists are already full of patients in a system where most pay out of pocket.

It is easy to see how the same pressures could possibly one day have a similar impact on general practice in Northern Ireland. Extra private fees are earned for each patient, but funding for NHS patients is set per person. GPs will benefit financially the more that they can add on.

In Northern Ireland, and elsewhere where GP contracts similarly allow private patients not on the practice’s list to be seen, a priority will need to be designing models which reduce these risks. Those who commission general practice would want to closely monitor what happens to NHS access and appointment numbers. NHS trusts have rules that private income cannot exceed NHS income, and must not “to any significant extent interfere with the performance by the NHS foundation trust of its functions”.

In reality though, this is only a more visible form of a tension over who GPs see, which has already played out in the working lives of individual doctors all over the UK. A 2022 YouGov poll for The Times suggested that 7% of people had used a private GP, of which almost half had done so for the first time within the last two years. More data is needed on this apparent expansion, but it will reflect part-time GPs shifting more of their time to the private sector, or leaving NHS practices for private ones.

Whether or not it happens in the same building, if the staffing difficulties and pressure on health service work encourage workers to move to the private sector, the risk of pushing patients to pay increases. If it comes to affect the ability to access the NHS, a two-tier system where the wealthy get more care and the poorer get less, regardless of need, will be the result.

Northern Ireland’s newly reformed government faces plenty of urgent problems in its health service. The decision at the Abbey Medical Practice highlights that letting them sit may result in further losing the capacity to deliver the care people need. And for other health services across the UK, it is a more visible manifestation of the problem they all face in keeping workers inside the strained systems they rely on to deliver care to everyone who needs it, free at the point of use.