Doc on call... after call, after call: 'We’re already 70% booked out by 8.30am every morning'
Left: Dr Laura Cullen at the Marino Medical Centre, Bantry, Co Cork. Picture: Dan Linehan; and Right: Dr Mike Thompson at Imokilly medical centre in Midleton. Picture Eddie O'Hare
GPs are the cornerstone of our healthcare system. Whenever we have a health issue, we are told to contact them for advice on how to treat it.
But what happens if they are unavailable? What if we have to wait days, even weeks, for an appointment? This is happening nationwide, as Ireland experiences a shortage of GPs.
“The unfortunate reality is that we do not have enough GPs to meet our needs,” says Dr Diarmuid Quinlan, medical director of the Irish College of General Practitioners (ICGP).
According to the Irish Medical Organisation (IMO), Ireland has 0.7 GPs per 1,000 people. That’s significantly lower than the recommended minimum of 1.1.
This shortfall can have serious consequences. “General practice is fundamental to delivering timely and equitable access to healthcare, supporting people to stay well in the comfort of their own homes, and avoiding unnecessary attendance at A&E and admission to hospital,” says Quinlan.
A Norwegian study published in the most recent issue of the proves his point. It found that patients who were regularly attended to by their GP had fewer acute hospital admissions and lower mortality.
The problem is set to deteriorate further in the years ahead, with the HSE anticipating a shortage of 1,660 GPs by 2028. The ICGP attributes some of this to the fact that an estimated 700 GPs will retire in the next five years.
The other issue is newly-qualified doctors being deterred by the stressful working conditions of Irish GPs and choosing to practice abroad or to specialise in another area of medicine instead.
“The average GP works 10 to 12 hours a day,” says Quinlan. “There’s a lot of invisible work in addition to patient consultations such as writing letters of referral, returning phone calls, and so on.”
There’s so much for them to do that the 2021 IMO Study of Doctor Mental Health and Wellbeing found that 57% of doctors were unable to take scheduled breaks during their working day.
They are reporting worryingly high levels of stress and burnout as a result. Nine out of 10 say they have experienced some form of depression, anxiety, stress, or other mental health condition related to or exacerbated by their work.
The pandemic has added to the pressure, with 36% reporting that they hadn’t been able to take any time off since the pandemic started and 79% reporting that their mental health had deteriorated as a result.
The Irish Examiner spoke to three GPs about what it’s like to treat patients when their service is under such strain.
Dr Denis McCauley, 59, is a Donegal-based GP and chairman of the IMO’s GP Committee. He says: “I work in a group practice with four others and we each see up to 40 patients every day. There’s more demand than there are doctors, which results in waiting lists of up to two weeks for non-acute cases.”
He feels guilty about this: “The success of our system depends on patients seeing their GPs quickly. It’s less worry for patients and ultimately results in fewer referrals to specialists.”
Yet there is little to do about it as he is already working to capacity: “I start at 8.30am and don’t finish until after 7pm. I even check blood results and complete paperwork at lunchtime.”
McCauley believes the seeds of the current situation were sown in 2008, when the payments GPs received for dealing with medical card patients were reduced by 40%: “That impacted our ability to attract young GPs. The number of GPs coming into the system was lower than the number retiring, so the workload went up for everyone.”
Covid exacerbated the problem. “We had to displace work then and it’s added to our workload now,” says McCauley.
Dr Mike Thompson is a GP in Midleton, County Cork. He is joined in his practice by an assistant GP, a part-time nurse, medical students from UCC, a GP registrar who is completing GP training, a practice manager, and four secretaries.
“Together, we offer approximately 320 appointments every week to the 4,000 or so people who are registered with us,” says Thompson.
The team is constantly under pressure to meet demand. He says: “We’re already 70% booked out by 8.30am every morning. We try to keep slots available for same-day contingency but those are usually gone by 9.05am. How can we then squeeze in the sick baby, the elderly person who’s fallen, or the suicidal young man?”
On the day he spoke to , Thompson had had 21 face-to-face consultations, 17 telephone contacts with patients, and one phone call to a consultant colleague. He’d also dealt with 64 letters or test results, reviewed and emailed 11 prescription requests, and attended an hour-long Zoom meeting with a diabetes group: “I will have worked a total of 71 hours by the time this week is over."
Dr Laura Cullen is one of three GPs working in a rural practice near Bantry in County Cork. The 42-year-old mother of two regularly works 10-hour days, trying to fit in as many patient consultations as possible: “I see up to 28 patients face to face, talk to another 15 or so over the phone, and do some house calls. I’m constantly under pressure and it’s never enough.”
Like all GPs, she is also required to work out of hours. The way this works is that all GPs in a particular area share the workload involved in providing medical care in the evenings and at weekends.
Cullen says: “At the moment, there are 18 GPs in my area, and we all have to work an extra eight to 16 hours a month But five are likely to retire in the next few years. I’m at capacity now in terms of the work I’m doing but I’m worried I’ll be put under pressure to do more when they go.”
According to the IMO study, 60% of doctors find it difficult to take holiday or sick leave because of the scarcity and cost of locum cover. Cullen says: “I’ve definitely worked through a few illnesses when I knew I shouldn’t have. I didn’t feel I had any other option.”
She even felt pressure to cut her maternity leave short. “I was working in a hospital when I had my first baby and took the full six months off. But as a GP, I had no cover for my second baby and went back after 10 weeks. That was hard, especially because she was often sick as a baby. There were times that I was by her side in hospital feeling guilty because choosing to be with her meant I was putting pressure on my colleagues.”
Cullen believes this lack of work/life balance is one of the biggest reasons why young doctors are deciding against working in general practice in Ireland: “They know that it no longer fits around family life."
This is particularly pertinent for women, according to Roscommon-based GP and IMO GP committee member, Madeleine Ní Dhálaigh: “We now have more female medical graduates than male and until now, many of them have chosen to specialise in general practice because it’s been seen as an area of medicine that complements family life. But at the moment, there are problems with this.”
One of these problems is advancement within the system. “GPs progress by moving from assistant positions to becoming principal GPs or partners within the practice,” says Ní Dhálaigh. “But that requires significant financial investment, and it can be daunting to take on that burden at a time when you’re probably still dealing with college debt, applying for mortgages, and worrying about things like the cost of childcare. Many women choose to continue as assistants instead.”
Steps are being taken to address these problems. The first is the IMO GP Deal with the Department of Health and HSE which restored GP payments to 2008 levels. The next is increasing the number of GP training places. The ICGP, which is the body responsible for training GPs, has committed to raising them from 258 this year to 250 by 2028.
Newly-qualified GPs will then have to be convinced that it’s worth working in Ireland, says McCauley: “The IMO is campaigning for supports to be offered to young GPs to set up in practice and for grant aid to be available for practices to take on additional nursing and administrative staff.”
The HSE should support young doctors "in the way the IDA offers grants to entrepreneurs setting up businesses,” says Ní Dhálaigh.
“The out-of-hours commitment also needs to be overhauled so that it meets patients’ needs without placing an unmanageable burden on GPs,” says McCauley.
Such changes could drastically improve our health system. “Our young GPs are trained to world-class levels and if encouraged and supported, they would give the HSE back multiples of its investment,” says Ní Dhálaigh.
The IMO report found that more than 80% of GPs still have a strong desire to practice medicine. Yet 39% also stated that they are not fully satisfied with their career choice. It’s that latter figure that worries doctors like Quinlan, McCauley, Thompson, Cullen, and Ní Dhálaigh. It’s why they are campaigning for change.
McCauley says: “I’m 59 now and continue to take great pride in my job. The past decade has been a dreadful one but by the time I retire, I hope the situation will have improved and there will be a future in general practice for young people.”
