Patients face entirely new model of GP care post-Covid: but where are all the GPs?

Patients face entirely new model of GP care post-Covid: but where are all the GPs?
  • No room on lists of Carrigaline’s 30 GPs
  • Clare towns seeing impact of GP shortages
  • North Tipperary GPs overstretched as colleagues retire

A visit to the local GP has changed almost out of recognition over the past two years, and while some changes are more than welcome, doctors warn staff shortages are a growing challenge already impacting patients.

The Irish College of General Practitioners (ICGP) recently informally polled about 900 doctors on whether they were taking on new patients or not. Over 60% said no, and said they were full to capacity or beyond.

The ICGP also estimated up to 700 GPs will retire in the next five years. That is 14% of the 4,716 GPs recorded as actively working full-time or part-time during 2020 by the Irish Medical Council.

All of this means in some areas of Ireland across urban and rural settings patients are already seeing delays to getting appointments and even in some places losing access to a local GP.

In Douglas, a suburb of Cork city, Rebecca Clarke O’ Shea waited almost six weeks for an appointment.

“I had cancerous moles removed two years ago and new ones have appeared so it was something I felt I needed to go to my own doctor with,” she said. “Otherwise to be quite honest I would go to South Doc or even a walk-in surgery.” Ms Clarke-O’ Shea considered going directly to a dermatologist but was told she needed a GP referral for this.

Tara Hamilton, waiting to see a doctor in Tallaght, Co. Dublin, said: “My GP will not give out appointments at the moment. They ask that you call into their surgery at 8am each morning to put your name on the GP list. Then they will see if they can give you a time slot for that day.” 

Cork GP Dr Diarmuid Quinlan is medical director with the ICGP and said they have found Ireland has 30% fewer GPs per head of population than England. Just a few weeks ago the ICGP did what he called an unscientific poll on this topic during one of their weekly educational webinars for GPs.

“We had over 900 doctors, and over 60% of them said their practices were not accepting new patients,” he said.

Dr Quinlan said even before the pandemic GPs in a number of Cork towns – including Youghal, Midleton, Mallow and Kinsale – were closed to new patients.

“That has now spread to the city,” he said. “What happens to all those patients then who do not have a GP? They’re using the hospital emergency departments or the out-of-hours as a de facto GP service.” 

Patients are also affected by shortages of the staff who support GPs. Dr Quinlan said, for example, the eight-doctor practice where he works has one nurse when a similar English practice would have five or more.

“We need more GPs, and then a multiple of the nurses, phlebotomists and healthcare assistants that we have,” he said.

Rural and deprived areas

The problem is most challenging for patients in rural areas and urban deprived areas, Dr Quinlan said, with problems also growing along the Border.

Dr Susan Smith, professor of Primary Care Medicine at the department of General Practice Royal College of Surgeons Ireland and a GP in Inchicore said communities in these areas rely on their GP and need them to be better resourced.

“Patients living in disadvantaged areas develop multiple chronic conditions about 10 years earlier than those living in the most affluent communities,” she said.

“Resourcing and care delivery needs to reflect this.” Almost half of GP practices around Ireland employ one or two doctors, the bulk of these smaller practices are in deprived areas.

Dr Quinlan said: “Many are doctors who are coming up to 65 and the pandemic has accelerated their plan to retire.” 

Since Covid-19 hit GPs have taken on a huge workload: triaging Covid patients, their normal work and then vaccination roll-outs. This has further impacted on the shortage, because doctors who usually provide cover are working on Covid-19 projects.

Over 2.5 million vaccine shots have so far been given in GP practices meaning thousands of vulnerable people did not have to travel to mass vaccination centres for their jab.

The sight of the over-80s venturing out in February, many leaving the house for the first time in almost a year is not to be forgotten. The joy and relief they expressed at being able to go somewhere familiar for this life-saving medication was a loud scream for the retention of general practice if ever one was.

At the end of September, New Zealand epidemiologist Professor Rod Jackson and other health experts met with the Irish vaccine team to hear how the Irish roll-out worked out so successfully. So far so good, and now GPs have started into the booster campaign and the annual flu campaign.

However, the unintended consequence of all of this is doctors who would normally be available to provide cover for busy weeks for their colleagues were caught up in the Covid programmes.

Many were working on contact training, vaccinations or even hired for full-time work by public health departments.

This is partially leading to the doctor shortages as highlighted in the Irish Examiner recently with doctors unable to take leave or even unable to get cover for maternity leave.

Attracting doctors to small practices

Small practices with a low number of patients are struggling to attract doctors who now have other options.

Dr Stephen Murphy, a GP trainer on the HSE Dublin Mid-Leinster (UCD) Specialist Training Scheme, said the case Irish Examinerhighlighted by the in Templemore where new doctors cannot be found to replace retiring GPs is sadly not unique.

“If you think about a young doctor going to Tipperary to start out, they might have to buy a house. Then they have to either lease, rent or purchase a surgery,” he said.

“They fit out the surgery, then they have to get staff. That is all taken out of the GMS budget (paid from the HSE), and whatever is leftover is our salary,” he said.

He said there are many theories for why some new doctors are less interested in general practice, saying some feel there is not enough commitment to general practice by the State.

“I would say there is definitely a move away from urban deprived and rural practices generally,” he said. “The new trainees don’t seem to be interested in going to those places and that is a concern.”

Positive changes for patients

Since January GPs can order X-rays, MRIs, CT scans and Dexa scans for bone density for their patients through “mini-tenders” in place between the HSE and private hospitals.

The programme was set up at speed to keep patients out of Covid-ridden public hospitals despite GP organisations having called for this for years to no avail. HSE data from when the scheme opened shows just 84 scans were accessed by GP patients to mid-January.

However, by mid-April 17,545 people had received one of these four scans through a GP referral. This is set to continue during 2021. This is all really good news for patients, especially the elderly who are anecdotally more hesitant to go to hospital during the pandemic.

Nenagh GP Dr Pat Harrold says GPs are “at breaking point...and it’s a national crisis.” Photo: Don Moloney
Nenagh GP Dr Pat Harrold says GPs are “at breaking point…and it’s a national crisis.” Photo: Don Moloney

Dr Murphy said it is also good news for GPs who get faster feedback on what ails their patients and can work instead of waiting for waiting lists to clear.

This access to scans is just one part of what is hoped to be a revamp of GP care as Slaintecare rolls out; giving more work to the community and keeping hospitals for acute care.

A key change for patients will eventually be universal access to free GP care. Of course that assumes there will be enough GPs to deliver this to a population of now over 5m people. This could be a stretch based on the current situation.

The Medical Council said in its latest workforce report Slaintecare could mean needing between 32% and 42% more GPs, depending on demand.

The report also includes anonymised comments from GPs explaining why they left the profession or even the country. One person talked about the “astronomical cost of indemnity insurance relating to duty in out-of-hours services”.

They described the “poor call centre triage system for out-of-hours services”, and said the service is used as an alternative to general practice not as an emergency service.

HSE data illustrates the high demand for out-of-hours services with 73,670 appointments clocked up at clinics around the country last September, rising to 96,710 in January this year.

Dr Quinlan said numbers attending out-of-hours GP clinics in Cork and Kerry have been rising this year. “We have very good data on that (nationally also) in terms of the numbers of patients seen, we know that is going up consistently,” he said.

Everyone is working harder and seeing more patients. The early data suggested people may be sicker, more complex.

So once again there is a pandemic twist. Hospitals and GPs say they are seeing patients who either had their care cancelled or choose to delay appointments out of fear.

As these people return to care and perhaps need more appointments or longer appointments than before, this also inadvertently puts further pressure on the system.

Prof. Smith said: “Many practices in Ireland no longer have available appointments for routine and preventive care on a same-day basis, which is a change from the past on some areas.” She sees practices adapting to offer care when it is needed and said, in common with other GPs interviewed for this story, same-day care is always available for emergencies.

Living longer with more complex conditions

Another good news story for patients which is inadvertently impacting access to care is people living longer or living with conditions which were terminal in the past. It is a positive development but its impact cannot be ignored.

“Modern medicine requires teams of healthcare professionals rather than single doctors to be delivered effectively,” said Colin Bradley, Professor of General Practice at University College Cork.

He said it is increasingly difficult for small or single-doctor practices to survive.

Historically though this is how GPs operated; one doctor per village with each GP also an employer and single-handed entrepreneur. If that model is becoming unsustainable, what is on offer for new doctors and their patients?

Prof. Bradley said doctors faced with working on their own know they have to navigate “ever more burdensome bureaucratic requirements” to get paid and survive. GPs do not like to focus on money as medicine is what draws them to their career, but at the end of the day someone has to pay the bills.

Prof. Bradley, who is also a GP in Cork, welcomed the recent reversal of recession-era cuts to general practice funding but said the cuts caused uncertainty around the profession.

PRESS RELEASE : ICGP calls for a Working Group on Future General Practice to plan for serious GP workforce pressures, in pre-Budget submission.

— Irish College of GPs (@ICGPnews) September 27, 2021

“Younger doctors, understandably, do not wish to even face the possibility of such major hassle,” he said.

“(They) are more keen to opt for a situation where they can apply their clinical skills without the added demands of running a business which has been seen to be so vulnerable to sudden shifts in government policy.” 

Tipperary GP Dr Lucia Gannon recently raised concerns about the future of the Maternity and Infant Care Scheme. Writing in the Medical Independent, she discussed how changes to payments are a “serious threat” to the programme.

This programme allows women to see their GP from diagnosis of pregnancy up to six weeks after the birth for a range of pregnancy-related conditions. Doctors are paid through the Primary Care Reimbursement Services (PCRS).

Dr Gannon writes however that lately payment for some treatment was refused and said the changes “hamper” the service. It is not the kind of news to entice more doctors into adding that programme to their list of services.

Increase in training places for new GPs

Curiously while these challenges seem to encourage many doctors to leave general practice before retirement age, they are not deterring people from starting out as GPs.

Training is run through the ICGP who are in the process of taking over the HSE’s role in GP training as well. The number of training places has grown from 150 in 2015 to 235 this year, and they plan to increase this again to 350 by 2026.

“The competition for places on GP training is still reasonably competitive by international standards,” Prof. Bradley said.

“There is an issue, though, with the number of training places available. 

While these have increased in recent years the increase in training places has not kept pace with the numbers of doctors leaving general practice.

The HSE is also watching the GP shortages with concern. A recent report noted the sector is “unique” in its need for substantial growth in trainees to meet the planned demands from Slaintecare.

Increasing training places is a complex dance involving students, medical colleges, the HSE, two government departments, hospitals and GP bodies. Dr Murphy said a further challenge is finding GPs who have the time to take on a trainee for a year and mentor them.

So a more pertinent question might be could more be done to support the middle of GP’s careers, so more doctors stay in the profession, and are available for patients?

One sticking point seems to be the seemingly never-ending re-negotiation of the contract between GPs and the State to replace an agreement dating back to the 1970s. Individual items have been re-negotiated, and Prof. Smith said a new contract would give “some certainty”.

“(The contract) needs to be fair and resourced according to complexity of patients being managed,” she said.

“There is also a need for supports for setting up in practice and imaginative ways to support practices under pressure, like expanding GP Fellows in urban deprived practice and rural locations.” The Irish Medical Organisation (IMO) called this week for greater investment across a number of areas they feel would help keep doctors in their practices.

One sticking point seems to be the seemingly never-ending re-negotiation of the contract between GPs and the State to replace an agreement dating back to the 1970s.
One sticking point seems to be the seemingly never-ending re-negotiation of the contract between GPs and the State to replace an agreement dating back to the 1970s.

Dr Ina Kelly, president of the IMO said the lesson of the pandemic was the need to maintain investment in health on an ongoing basis. They called for funding to allow GPs to hire more doctors, practice nurses and other support staff. 

This could include physiotherapists for example so patients could be quickly referred to the right professional. Direct funding for mental health and women’s health would address more challenges facing patients, the IMO urged.

If even some of the changes were funded and implemented, it could boost access for patients and give a breather to an under-pressure system.

Prof. Bradley said, while he thinks the situation could get “a bit worse” for patients and GPs before it improves, that ultimately: “I would wish to point out that these problems, while challenging, are not beyond solution.” Dr Quinlan echoes this cautious optimism.

“I am confident there is a need for more GPs,” he said.

“It is challenging, but we are working with the HSE and the IMO to address these challenges. I love what I do, I love going to work. It’s a huge privilege to be a doctor and to be a GP is the best job in the world.”

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