GP Lucia Gannon fears for the future of rural doctors. She tells Áilin Quinlan the government must get to grips with the shrinking numbers of GPs that threaten the health of small communities across the country.
Bridget Mary Durkin hadn’t set foot outside her house for more than 30 years. Aged 83, she lived in a state of freezing squalor in a secluded farmhouse a few miles outside the Co Tipperary village of Killenaule.
The emergency call came in just as local GP, Dr Lucia Gannon finished her day’s work and minutes before the out-of-hours emergency service opened.
There was no question that Gannon would even think of passing that call on to a different doctor — Bridget Mary, she recalls, would only allow a certain few into her house, and Gannon was one of them.
“I had never managed to get her to discuss how she had come to live in such isolation and why she would not leave her house,” she recalls.
“Diogenes Syndrome is a rare disorder, named after the Greek philosopher Diogenes, which I had only ever read about in my psychiatry textbooks, but Miss Durkin exhibited four of the commonest components of the condition: self-neglect, domestic squalor, compulsive hoarding of rubbish and social withdrawal.
“Ragged and stained full-length curtains hung like sails at half-mast on the windows of what would once have been the parlour.
"This was where she usually received me,” the GP recalls, adding that what disturbed her most about her visits to the house was the sight of the little bowls of blue pellets placed strategically adjacent to small and large holes in the skirting.
On this one particular evening, Miss Durkin had been found on the floor by a neighbour who called the doctor. After examining her, Gannon felt she needed to be brought somewhere warm and safe, but she was also aware t the old lady had a profound fear of hospitals.
“Knowing what she was like, I was able to come up with a plan that she would go to a nursing home.
“If I had been a doctor on call arriving at the scene I wouldn’t have known what to do with the lady,” she says now.
“I’d have struggled to find a solution to the problem. She knew me. We had a relationship over the years during which I would visit her at home and she trusted me not to force her to do anything against her will.”
There are many advantages to being a rural GP, says Gannon. One of the biggest is that you tend to know your patients well.
Gannon who arrived as a blow-in more than two decades ago, has served the local population of between 500 and 700 people ever since.
Now the mother of three adults in their 20s, Gannon moved to the village in 1996 with her husband Liam Meagher — also a GP — and their two young children, to take over the village’s existing practice from a retiring doctor.
The couple, who along with their children once competed in the RTÉ series Ireland’s Fittest Family, built their own medical centre and have run a busy practice on the outskirts of the village ever since.
Rural Irish practice has its downside — the Galway native recalls with some nostalgia how earlier in her career as a GP registrar in Derbyshire in the UK, she had loved doing house calls.
“I would take my list of people to visit and set off in the early afternoon, taking my time, enjoying the scenery, listening to the car radio, before calling to a neat little house in a neat little village, occupied by an even neater little old man or woman, who needed a repeat prescription or had to have their blood pressure checked.
“Even the country lanes had names in Derbyshire and all the houses were numbered in a logical sequence.”
Doing house calls in Tipperary was not quite the same, she observes “There never seemed to be enough time. I was always getting lost on country lanes, wrecking my shoes in mucky farmyards and gingerly making my way past unfriendly dogs,” she recalls.
However, the warmth of the community she and her husband have served for some 23 years, makes up for those physical discomforts:
“Now that I’m older, I feel people care about me, and the children and my husband; they feel connected to us and know we have their best interests at heart.
“There’s a real feelgood sense to being a long-term GP in a small community. I believe the community has embraced us even though I come from Galway and Liam comes from Mayo,” she remarks.
And yes, being a GP and a mother-of-three did mean constant juggling:
“There’s always a balance going on, trying to balance career and motherhood with my availability to the public and to my children,” she says.
“In general practice there’s a lot of work done behind the scenes, and as a rural GP you’re running your own business so you’re never off-duty.
“You’re doing everything from managing staffing issues and arranging cover for the secretary if she’s out sick to ensuring the toilet works. Diseases are more complicated now. Prevention is more complex and medico-legal issues are more complex.
"A huge amount of paperwork, thinking, planning and organisation goes into a doctor sitting in front of you for a face-to-face consultation.”
It’s a busy profession and getting ever busier as a result of falling GP numbers nationally, says Gannon, who will generally see between 20 and 30 patients in a full day.
Unless the government gets to grip with the shortage she warns, the writing’s on the wall for rural communities: “A local GP retired in a village not far away and although the job was advertised for three years nobody applied for it.
“There are a lot of GPs due to retire around the country in the next five years. The age profile of GPs is older and there are no people coming up to fill these posts.”
In her book she identifies the root of the problem as the series of cuts in government funding to GPs over the recession, to the extent that, by 2013, the sector had experienced a 38% reduction in pre-expenses income. These cuts, as she points out, were never reversed.
Alongside this reduction in income, says Gannon, demand for free GP services was increasing, as was the complexity of the diseases being treated and the expectation that GPs take on more and more responsibility for chronic disease management.
"Not long ago, I read an analysis of the reasons for the collapse of the road bridge in Genoa in August 2018. “The author stated that the bridge did not have enough structural redundancies, so that when one cable gave way, the whole bridge collapsed.
“It struck me that general practice, like the bridge, has no structural redundancies.
“These have been deliberately removed, causing the structure to grow weaker under the ever-increasing traffic, leaving it in danger of complete collapse.”
The single biggest disincentive for young GPs, she warns, are these emergency cuts to GP funding.
“The 40% cut is making all the younger GPs nervous because you simply cannot build a business with the amount of government funding allocated to GP practices.”
She and Liam, she observes are now well-established. The mortgage on their clinic has been paid off, but in terms of their retirement, the future of the clinic is uncertain — Gannon cannot see any young GP taking over the couple’s practice when they retire:
“They won’t be able to afford to do what we did because they’re getting less money now than we got; the expenses, are higher, the diseases are more complex, the fixed costs are higher and the funding is less.”
Living where they do, she says, she doubts that she and her husband will have a GP to look after them in their old age:
“No young GP would feel secure that this is a sustainable way of life and that’s why they’re not coming to places like this.”
Her fears for the future are graphically illustrated in a final consultation with a patient she had known for years.
The young woman, who had previously confided in her about the strain she was experiencing in the Leaving Certificate years, now needed a contraceptive implant procedure before leaving for college.
“It was always a bittersweet experience when young people gained entry to college and set out on the next part of their life’s journey,” Gannon recalls.
“Just as I had to let my own children go, I had to let these young patients go.
“I made my note and closed her file.
“My next appointment was already waiting, a young mother with her new baby.
“If she would have anyone to consult when she felt exam pressure, anyone to provide a contraceptive implant or to feel a tinge of sadness as she left Killenaule and moved into the wider world.”
All in a Doctor’s Day: Memoirs of an Irish Country Practice by Lucia Gannon, published by Gill Books, €16.99