General practice under pressure

With the extension of free GP care and a strategic review of general practice imminent, doctors warn the system is under severe pressure. David Lynch reports

There is a significant amount of policy focus on general practice currently. As announced in Budget 2023, from April, eligibility for GP care without charges will be extended to people who earn the median household income of €46,000 or less. A shift within the health system towards primary care remains a major goal of Sláintecare, while a national strategic review of general practice
is imminent. 

Minister for Health Stephen Donnelly told the Dáil last month that a “central objective of the Programme for Government is to deliver increased levels of integrated healthcare with service delivery reoriented towards general practice, primary care, and community-based services”.

While the future of general practice is a major focus of health policymakers, many GPs are struggling just to meet existing demand.

In this newspaper in January, GP Dr Lucia Gannon wrote that face-to-face clinical practice is only one aspect of a GP’s workload.

“Organising referrals, checking blood results, checking discharge letters, updating medical histories, and medical reports must all be done ‘in our own time’, before the first patient appears and the last one leaves,” she wrote. “In addition, there is practice administration, staff meetings, human resource issues, submitting claims, and the myriad other tasks involved in managing a business.”

Like many other GPs, Dr Gannon observed that general practice “is in the midst” of a workforce and workload crisis.

Stress

“Listen, right now the demand is probably greater than the capacity of general practice,” Chairperson of the IMO GP committee, Dr Denis McCauley, told the Medical Independent (MI). 

“Coming out of the Covid-era we’re actually busier than I think we were before [the pandemic]. One of the reasons is we are spending a lot of our time trying to get people seen quicker in the hospitals, and treating people while they’re on a waiting list.

“There’s an awful lot of extra work associated with the logjam, which is the hospital system problem.”

Speaking about his own experience working as a GP in Co Donegal, Dr McCauley said: “Even as we speak… I have to triage what’s important today and what can wait until tomorrow… much more than I have ever done before. The stress associated with that is actually very high.”

The extension of eligibility for GP care without charges next month has Dr McCauley and other GPs worried and he expressed serious doubts that the system can cope.

He said there has been no “significant discussions” between the IMO and the Government on this expansion of eligibility.

“Yes, they [the Government] have committed that they are going to do it,” he said. “But we are just alerting them that we are not happy; we as a union are not comfortable and are very wary about these decisions. The Government are not sure how many people will come in [to eligibility] with this income limit; that’s the first problem,” he told MI.

‘Free’ care

Dr McCauley said new patients being eligible for free GP care will lead to more GP visits and “waiting lists will be created and it will be a politically generated waiting list”.

He added that it will “increase the demand to a system that can’t cope”.

Commenting from his own perspective as a GP, Dr McCauley said: “I won’t be able to manage. I like general practice, I love the interactions, but the pressures associated with it now… is actually quite stressful.”

He predicts that older GPs will retire, but that younger doctors will be reluctant to enter general practice to replace them.

“Guess what? That is going to increase the capacity problem.”

At present, general practice sees both public and private patients, and until recently, most patients were seen on the day they presented, according to Dr McCauley.

However, he warned that the extension of free GP care without greater capacity would in fact result in greater inequality in the system.

Two-tier GP system

“This is going to cause a two-tier GP system,” Dr McCauley argued.

“General practice treats public and private patients the same. If you give everybody medical cards, patients are not going to be able to get to see their GP, even though its free. So, what are you going to do? You are going to go to a purely private GP. So, it will create a two-tier system.”

He added: “With Sláintecare, remember, it’s meant to be timely care… free at the point of access.”

Dr McCauley warned that with insufficient numbers of GPs in the system, patients may have eligibility for free care, but they will be waiting to see a GP.

He called the extension of free GP care a “short-term political fix” that could potentially “destroy” the current general practice system.

In addition to the extension of eligibility based on income, free GP care for all children aged six and seven was due to be introduced at the end of last year. However, this latest target was missed. Minister Donnelly told the Dáil last month that the Government is currently working on the eligibility extension, which would include approximately 70,000 children.

In January, research published by the Economic and Social Research Institute (ESRI) found that extending free GP care to all by 2026 would cost the State between €381 million and €881 million. It was estimated that there would be an additional 1.9 to 2.3 million GP visits in 2026 if free GP care is extended to all. 

However, one of the authors of the work highlighted the lack of GPs as a serious challenge to such a policy.

Demand

Dr Sheelah Connolly (PhD), Senior Research Officer in the ESRI social research division, said Sláintecare noted the need to move towards a universal healthcare system for Ireland.

“Increasing, the number of people entitled to free GP care would help achieve this objective,” said Dr Connolly on the publication of the research. “However, there may not be a sufficient number of GPs available to deliver the additional visits associated with the ageing and growing population, as well as an increase in the number of people eligible for free GP care in the coming years.

“If there are not sufficient GPs to meet the additional demand for their services, then, while financial barriers to access may be removed, other barriers including long waits or no availability could hinder access, thereby undermining the universality of the system.”

From the IMO perspective, Dr McCauley said politicians need to “listen to experts”.

“During Covid they took our advice. The Government and Department listened and interacted with us,” he told MI.

“Now we have the IMO, we have the College (ICGP), we have the ESRI, all experts raising concerns.”

He did not just blame the Government. “Where is the opposition?” he asked. “It’s a zombie Dáil.”

Review

Last month, Minister Donnelly told the Dáil that a strategic review of GP services will commence shortly and will be completed this year.

“The review, with input from key stakeholders, will examine the broad range of issues affecting general practice and will set out the measures necessary to deliver a sustainable general practice into the future,” the Minister outlined.

However, the IMO GP committee Chair thinks this review will be investigating a system that is overwhelmed by growing patient demand. He said that while he agreed with the extension of free GP care to those under the income limit, “you have to do it at a level that capacity allows.”

“There is no good doing a review, if the system has been wrecked by your previous political decision,” said Dr McCauley. “It is absolutely nonsense. They don’t know how many people [will become eligible for free GP care]; they haven’t got a clue.”

For its part, the Department said last month that the measure would mean “that almost half of the population will have access to free GP care”. The Department also said it is “envisaged that these measures will be supported by a significant package of additional capacity supports to GP practices”.

Dr McCauley said that any strategic review of general practice would be better taking place before any extension of eligibility for free GP care.

“I think what they have got to do is… ensure there is capacity and infrastructure in general practice following a strategic review, to see if there is enough capacity,” he said.

“And then introduce the amount of medical cards that the system can accept. We can then have the GP cards in a system that is working whereas now we’re doing the complete opposite.”

This will mean that GP contracts in these areas need to be given additional incentives, extra supports that address the additional healthcare needs, support for infrastructure…

Incentives

However, despite these concerns, the Department of Health-led review of general practice  is set to go ahead. The Department told MI that details of the review would be announced shortly. So, what major areas should it focus on?

Prof Susan Smith, GP and Professor of General Practice at Trinity College Dublin, told MI the “key priorities” of such a strategic review would need to be “addressing the recruitment and retention crisis” within general practice.

Prof Smith is also a member of Deep End Ireland, an organisation of GPs working in some of the most socio-economically deprived communities in Ireland.

She added the review would need to keep in mind that such workforce challenges “has greatest impact where healthcare needs are highest”, which is in “urban-deprived and rural areas”.

“This will mean that GP contracts in these areas need to be given additional incentives, extra supports that address the additional healthcare needs, support for infrastructure; for example, not having to pay rent in HSE owned and run primary care centres,” Prof Smith said.

Are there any achievable changes that could be made to general practice that would improve services in the short-term?

Prof Smith pointed to the need for “planning of services based on healthcare needs”.

“We increasingly have data that can support resource allocation based on need,” she said. “At the moment, we don’t really plan services or allocate resources based on socio-economic differentials in need and we could start doing this.”

A critical example, according to Prof Smith, is primary care services for children with mental health and disability issues.

“Services are poor across the country and there are challenges with recruitment that mean it will take time to improve services,” she said. “Meanwhile, in more affluent areas, people can afford to use private services, which takes some of the pressure off the public services in those areas.

“But in the most disadvantaged areas where needs are significantly higher, the public services are under considerable pressure.”

She said that she believed the existing resource “could be managed more efficiently” to address this situation.

RHAs

The strategic review of general practice will also be taking place against the backdrop of one of the largest reform changes in the history of the Irish health service. The creation of the six new regional health areas (RHAs) will significantly impact primary care.

“GPs need to be at the centre of” the reform, Kilkenny GP Dr Ronan Fawsitt told MI.

Dr Fawsitt is also a member of the RHA advisory group. He insisted that GPs have a crucial role to play in the new structures.

Dr Fawsitt said, currently, GPs “are not really aware of it, it’s not on their radar. We have had so many promises and false starts with primary care plans, different reports, Hospital Groups, CHOs [Community Healthcare Organisations] and now we have RHAs. So they are thinking ‘are we moving the deckchairs on the Titanic?’. But we’re not.

“This is a fundamental reform and change and general practice needs to be at the heart of it.”

He added that GPs need to “develop a local voice at every acute hospital in Ireland”.

“I… think that general practice needs to be at the heart of the regional health areas; there needs to be representation on the RHAs in each of the six regions.

“I think there is no way you can move care out of the hospitals into general practice without involving GPs in its design and delivery. It will not happen. I think the earlier we are involved in that the better.”

Speaking to this newspaper at the National Health Summit in Croke Park last month, Dr Fawsitt said GPs have an important role to play in the new structures.

“Governance at the top and governance at the local level is key to this,” Dr Fawsitt said. “You need clarity on the roles between the Department and the HSE, clarity on who reports to who.”

“We need the RHAs to have financial autonomy, to have clinical independence [while] following national guidelines….how populations are dealt with must be left to the regions to decide with their local patients and with their community.”

Dr Fawsitt said the six RHA areas “are quite different, in size, scale, and demographics and they will require different solutions”.

“I think that is where GPs, who know the patients better than anybody to be honest, can have a real voice on how the funding goes, where the services are.”

He added: “We [GPs] can’t be quiet about this anymore.”

Collaboration

While critical of Government plans for extending free GP care without sufficient capacity in the system, Dr McCauley contrasted this experience with the creation and “success” of the chronic disease management programme in general practice.

“When there was collaboration between good sensible men and women in a room having sensible discussions, we generated something that is ‘world-leading’,” said Dr McCauley about the programme.

“This is really good. It’s fantastic. You know, it shows, we can work in collaboration with the Government for the benefit of the patient. That is one example of where it works well.”

In contrast, he described current workforce issues as a “politically generated health crisis”.

“A crisis, where I think the [general practice] system is going to be destroyed and I think you will have private GPs even in rural parts of the country.”

He said patients will have a two-tier system in general practice and that will be “on the backs of the Dáil, not just on the Government. Because they are not thinking and not asking questions.”