The next year promises to be a difficult one for the Health Service in Northern Ireland - difficult for politicians, managers, doctors and other health professionals, but most importantly, difficult for patients.
It is almost certain there will be further cuts to the health budget. If the Health and Social Care (HSC) Board and the Department of Health Social Services and Public Safety (DHSSPS) impose cuts on trusts, it is likely that services will be withdrawn and waiting lists will get longer.
Doctors would prefer to ensure that front-line services will be maintained; budget cuts should address inefficiencies. Job losses and recruitment freezes among staff who deal directly with patients will be a false economy.
In Northern Ireland, the HSC Board is meant to commission services from the five local hospital trusts. These trusts provide hospital care and community services such as district nursing, health visitors and social services.
The HSC Board funds the care provided to the people of Northern Ireland and is responsible for meeting all health needs within the strategic framework determined by the DHSSPS and the minister.
The board tends to place contracts on a historic basis with annual uplifts. Trusts frequently fail to meet their targets and patients and doctors suffer the frustrations of long waiting lists, poor communication and the worsening of health conditions and illnesses.
The BMA's GP committee has been encouraging the board to permit commissioning of services by groups of GP practices in association with other health professionals.
The GP committee envisages practices coming together and commissioning services for populations of 50,000-100,000. These practices would work with other health professionals and patients to agree with the local trust how to meet the health needs of their population.
Together the groups would look at both hospital and community services as well as holding the prescribing budgets for the practices. Care would be designed around the patient and how best to meet the needs of patients in the locality.
This local focus would take account of geography, services presently existing and the wishes of local people on how they want to see local services developing.
GPs do not wish to dominate these groups, but as the group that generates around 90% of secondary-care referrals and almost 100% of elective care, the GP committee believes GPs are ideally placed to lead the groups.
While GPs will see their workload rise if waiting lists rise and secondary care comes under pressure, those that will suffer most will be the patients.
GPs believe many services can be delivered closer to patients and that there are alternatives to referral to secondary care that are more cost-effective and convenient for the patient.
These include better access by GPs to CT and MRI scans, endoscopy and cardiology investigative services and the ability to provide services normally available only in hospital in primary care.
Holding a real budget also allows rationalisation of prescribing and the possibility of common formularies between primary and secondary care leading to greater efficiency and savings.
Will it happen? If the department and the HSC Board have the courage to devolve responsibility to primary care, I believe GPs would be willing to take up the challenge.
Dr Brian Dunn is chairman of the British Medical Association’s general practitioner committee