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no doctors in the house

The 'workhorses' of the health service: How Ireland's GPs are under increasing pressure right now

“I have seen the ups and downs of general practice. I have seen it when it was sneered at, when it was dismissed”

IF THE COVID-19 pandemic taught us anything, it is the central role of general practice in the delivery of healthcare in Ireland.

Throughout the pandemic, general practice remained open and was often the first port of call for vulnerable patients dealing with the rapid change of Covid restrictions and regulations.

Coupled with their day-to-day work of caring for patients throughout the pandemic, GPs and practice nurses also arranged for Covid testing, manned Covid care hubs, and delivered more than a million Covid-19 vaccinations.

GPs undertake more than 29 million consultations a year with an additional one million-plus appointments in out-of-hours services.

From antenatal care, 6-week checks for newborns and childhood illnesses to chronic disease management and palliative care, GPs uniquely take care of their patients from the cradle to the grave. And they do all this under a contract that is more than 50 years old.

The current General Medical Services (GMS) contract dates back to 1970 and apart from some additions and amendments over the years, it is 52 years old and in no way reflects modern day general practice.

The ICGP, the professional body for general practice in Ireland, estimates that in excess of 700 GPs will retire in the next five years. Many of these work in single-handed GP practices, especially outside major urban centres. Many Irish GPs are over 65 and have indicated that the Covid-19 pandemic and workload may accelerate their retirement plans.

Dr Diarmuid Quinlan, Medical Director of the ICGP, said, “Ireland has approximately 3,600 GPs. This is 30% fewer GPs per head of population than England, and fewer again than Canada and Australia. We simply don’t have enough GPs.”

“The ICGP is working closely with the HSE to substantially expand GP training places, which have increased from 159 in 2015 to 258 in July of this year and are scheduled to reach 350 by 2026. However, GP training in Ireland is four years in duration – this is not a ‘quick’ win, albeit it is an essential step in the right direction.”

The ICGP has asked the Minister for Health to set up a working group to plan and deliver the future of general practice in Ireland. “This is required as a matter of urgency,” Dr Quinlan said. 

Changes

Coupled with the manpower crisis, GPs in Ireland today are also being asked to do increasingly complex work without extra resources, and patient expectations have also increased.

Not surprisingly after the intensity of working on the frontline of the pandemic for the past two years, many GPs are exhausted; however, the manpower crisis also means it’s incredibly difficult to find a locum to allow them to take a much-needed break.

Dr Knut Moe is a GP with the Churchtown Family Practice in Dublin, and Director of the Network of Establishing GPs (NEGs) with the ICGP.

Dr Moe said the pandemic had “changed the demands on general practice, and while we are quite adaptable, that comes with a price in terms of stress levels, in terms of burnout, and the increasing level of out-of-hours that is being required. I think there has been a slight reticence for some people to go into general practice.”

In relation to younger GPs, Dr Moe said that some were reluctant to go into partnerships in practices because of the onerous workload that comes with that role, and there has also been a reluctance to work in rural areas where there is little or no support and a requirement to provide 24/7/365 cover.

Younger GPs are also rightly looking to achieve some semblance of a work/life balance and are not prepared to work 24/7 in general practice at huge cost to family and personal life like their older colleagues did.

Balance

Life for a full-time GP in Ireland is incredibly busy with many working from 8.30am to 6.30pm seeing patients, with a half hour for lunch, which is usually taken at the desk. Then in the evening paperwork can mean they are working up to 10pm at night.

“That’s not sustainable and our older colleagues who are approaching retirement age have been doing that for a long while and it’s just not healthy… from a self care point of view,” Dr Moe said.

He added there was a need for protected time for GPs to deal with the increasing mountain of paperwork that comes with the job, explaining that six hours of clinical work could generate up to four hours of paperwork.

He also suggested that a hub and spoke model or network of GPs be established to help support those working in more rural areas.

“The days of single-handed GPs in some parts of the country are really quite numbered because it just doesn’t make sense. It’s not tenable for somebody to work in a single practice in a very remote area without having the support of a network.”

Dr Moe said that the problems in general practice were not about the money but rather the working conditions and supports needed.

Dr Moe’s wife is also a GP in the Churchtown Family Practice and he said it was “a perennial struggle” trying to get annual leave cover.

“It shouldn’t be this hard to get cover,” he said.

Despite the increasing pressures Dr Moe said he would encourage people to take up a career in general practice.

“No two days are the same. No two medical problems are the same. It’s a real privilege to have people come to you for care from the cradle to the grave. It’s definitely challenging. It’s really fulfilling [but] it could be easier. Everything could be easier, and across the healthcare system there are absolutely things that could be improved.”

A very different profession

Professor Tom O’Dowd is a practising GP in Tallaght Co Dublin, Emeritus Professor of General Practice at Trinity College Dublin (TCD), and President of the ICGP.

Prof O’Dowd has been a GP for more than 40 years and knows more than most the challenges his profession has faced over the years.

According to Prof O’Dowd, general practice has been “transformed” over the past three to four years due to to the introduction of the chronic disease management programme and initiatives such as telemedicine and e-prescribing that were brought about as a direct result of the Covid-19 pandemic.

The chronic disease management programme in general practice entitles certain patients with a chronic illness such as type 2 diabetes, cardiovascular disease, and asthma to two free checks a year with their GP.

Prof O’Dowd agreed that general practice today was a very different profession to the one he joined more than 40 years ago.

“It’s incredibly intense. It’s fraught with difficulties, patients have higher expectations, but you learn to work with that. I suppose so far, I’m a survivor. I feel a lot of us who have gone on this long are survivors and we enjoy what we do. We have been flexible enough to adapt.”

Despite the obvious manpower crisis and increased pressures, Prof O Dowd said that he wasn’t worried about the future of general practice.

“I have seen the ups and downs of general practice. I have to see it as being the workhorse of the health service and being recognised as the workhorse of the health services.

“I have seen it when it was sneered at, when it was dismissed. I have seen it when senior civil servants just didn’t get it. I have seen it when politicians said, ‘oh throw them a few bob,’ and I have seen it emerge from all that into a vibrant, important service that is in people’s corners. There is no doubt about it – we saw that early on in the pandemic. Where did they turn to? They turned to us. There were a lot of places that shut up shop, but the GPs didn’t.”

He added that younger GPs today were very much committed to general practice.

Prof O Dowd said that GPs are now trying to balance a lot of different types of work.

“You can’t pour a quart into a pint pot if we are doing Covid work and if we are doing chronic disease work then there is other work that can’t be done,” he said.

Prof O Dowd said that another big change in his lifetime was the development of general practice nurses who he said have “rolled their sleeves up and embraced change.”

He added that he would like to see the number of GP nurses double and for them to get the same pay and conditions as their hospital colleagues.

Prof O Dowd said he would encourage people to go into general practice and his son is currently training to be a GP.

Asked for his view on the future for general practice in Ireland Prof O Dowd said, “the future is guarded. It will require leadership, resources, it will require us to communicate.”

Prof O Dowd added that the ICGP was currently looking at the future of general practice and was “likely to come out with quite radical proposals…and some of these won’t require money, some of them will require a change of attitude.”

The ICGP will be launching its report on the future of general practice in Ireland at its AGM in June. 

This work is also co-funded by Journal Media and a grant programme from the European Parliament. Any opinions or conclusions expressed in this work are the author’s own. The European Parliament has no involvement in nor responsibility for the editorial content published by the project. For more information, see here

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