How are GPs supposed to cope with the expansion of free care?

There are welcome measures in Budget 2023, but the pressure it puts on general practice is unsustainable.

At the time of writing, Budget 2023 has just been announced. Although the main theme seems to be how cold we’re all going to be this long expensive winter, there was plenty for those of us who closely watch the allocation to the health service to get our teeth into. 

As part of the billions and billions of euros for the annual black hole that is the health budget, a key announcement that has caused the most consternation among GPs is the plan to increase the number doctor visit cards to over 400,000 more people. This has been promised to be accompanied by a “significant package of extra capacity supports”, according to the Department of Health. I’m very interested to hear what these extra capacity supports actually mean in practice – unless Stephen Donnelly can find an extra couple of hundred GPs and practice nurses down the back of his sofa, this is only going to put even more pressure on a primary care system that is already struggling to function. 

I obviously support the notion of free access to healthcare at the point of use to all those who need it. However, at this point, we all know the statistics about the aging population of GPs, many of whom have already reduced their sessional commitments after the long exhausting years of Covid as they ready themselves for retirement in the next five-to-10 years. A lot of this increased capacity seems to rely on a plan to increase numbers in GP training. But this takes several years and there is a ceiling on how high the number of good quality GP training places can feasibly be increased. This is even before you consider that any pipeline of new GPs will continue to leak as long as Canada, Australia, and New Zealand still exist. 

If we aspire to a system like the NHS, we also have to consider whether we aspire to their waiting lists – there is little benefit to a free GP appointment if you can’t get it until three weeks’ time. Increased demand will inappropriately push yet more routine care out to supposed ‘emergency’ out-of-hours services, which are already cracking under the pressure. 

The Government has already struggled to reach agreement with GPs to expand free care to six- and seven-year-olds. I simply cannot see how we have the capacity to see even more children. Thankfully, the majority of children are well, but they also have a number of self-limiting viral illnesses. 

Without wanting to put the blame on patients, it does seem that any lessons learned during Covid around the self-management of minor illnesses have been lost. “The antigen test is negative so I need an antibiotic,” seems to be the prevailing mood this autumn. The HSE had good messaging a couple of winters ago with the ‘Under the Weather’ education campaign, but that now seems to have fallen by the wayside. Something similar should be relaunched this winter because it’s just not possible that we can continue to see every viral cough and cold that has “gone to the chest, doctor”. 

To be fair, there have been good initiatives in recent years and in this Budget that are making general practice more financially sustainable and professionally meaningful. A year or so in, I really enjoy the chronic disease management programme. It may sound sad, but seeing someone’s Hba1c or cholesterol come down is an objective win in a job where they can be few and far between. Patients also seem to really value their six-monthly ‘NCT check’ and their time with their doctor and nurse now that the programme is really beginning to bed in. 

The recent introduction and announced expansion of free contraception is another great step. I would happily insert coils and Implanons all day long if I was let. But again, these are longer consultations and finding time in the day to schedule them in amongst all our other increasing demands is a challenge. 

Thankfully, previous winter initiatives now seem to be an all-year staple, with access to community diagnostics being a real game changer. The ability for patients to access imaging and investigations without referral to secondary care has made a big impact on how effectively we can do our jobs. Of course, it’s the private hospitals and imaging providers that are profiting from the State’s inability to effectively run their own health services. Imagine if all that funding was spent directly on HSE services rather than lining the pockets of private companies? 

The main takeaway from this Budget is that general practice is expected to carry the brunt of the work that the rest of the health service cannot cope with. As a brand-new GP fresh off the scheme, I’m bright eyed and enthusiastic right now, but I cannot see how any of this is sustainable into the future.