Liz Dunphy: Can Covid-19 ultimately save our GP service?

The recent crisis may have shown us we can maintain our health better than we thought, taking pressure off packed GP surgeries, writes Liz Dunphy.

‘We're on a war-time footing,” Dr Mike Thompson said from his GP practice between fielding calls from concerned patients and hand-writing referrals for Covid-19 tests after the online system crashed under hectic demand.

“At the moment we’re on lockdown and only seeing patients with an urgent need.

“I suspect this [Covid-19] is going to change general practice medicine — and that’s no bad thing.”

Based in Midleton, a rapidly expanding commuter-belt town in East Cork, the problems Dr Thompson and his fellow GPs there face are mirrored in towns and villages all over the country.

Recruiting GPs to the area is tough. People can no longer sign up with their local GPs and instead turn to emergency services like SouthDoc — which provides out-of-hours urgent medical care in Cork and Kerry — for routine visits.

And this misuse of the service is causing havoc. As GPs increasingly refuse to work in those areas with the most crippling out-of-hours burden, more patients who cannot see a GP by day rely on SouthDoc at night or weekends.

“South Doc is a catch-22,” said Dr Thompson.

“But I think it’s going to change forever after the Covid outbreak. Before, about 80% of what we saw in SouthDoc was routine and did not need to be seen.

“But triage has got a whole lot better now and people are learning to manage themselves. It’s good for GPs to see that the world didn’t fall down.

“We’ll be able to say: ‘Look, you’ve managed before. Take a paracetamol. Taking an antibiotic at 11pm at night won’t make any difference anyway.’

“Before, anyone who wanted to be seen by SouthDoc after consultation with a nurse could still demand to be seen by a doctor. But that’s forever gone. So we can go back to just seeing the 20% of urgent cases out-of-hours.

“We’ll still be available for the cuts, the catheters, the foreign bodies in eyes, the cases that do need to be seen. But three weeks with a cough, no temperature, and ‘just a check-up before we go to Lanzarote’ is not appropriate.

Dr Mike Thompson, Midleton-based GP

“SouthDoc is a very precious and finite community resource. It has been open to abuse and it’s now failing.”

Weaning people off services like SouthDoc for routine medical attention will ultimately protect general practice by making the prospect of working in towns and villages more appealing again, Dr Thompson said.

“It’ll be good for everyone. It’ll be cheaper for the country, increasing self-management for the population which has probably been eroded over the last 10 years. General practice will become more attractive to graduates because there’ll be a work-life balance.”

Telemedicine is also here to stay post Covid-19, Dr Thompson said. He also advocated for community pharmacies and nurse practices where patients could be treated for minor ailments which would reduce the queues in surgeries and take pressure off GPs.

Because if things don’t change, he said, the outcome is stark.

“Towns will not have a GP. I think general practice will become a south county Dublin and city-based speciality, which is not ideal, because 40% of Ireland is rural.

“People already can’t get onto GP lists in towns all over East Cork, Macroom, Bandon. That unmet demand has been pushing into SouthDoc, but SouthDoc is now going to push back.

“It has to. Because we can’t attract GPs if it continues.”

Currently, Dr Thompson works 210 SouthDoc hours on top of his regular, full-time hours. Weekend shifts run from 9am to 11pm, on both Saturday and Sunday.

“By the end of that, I’m neither safe nor nice. You would not leave a pilot do that,” he said.

“And over that weekend, between the three doctors on duty in SouthDoc Midleton, we could have 514 appointments, which is farcical.

“Some 22,000 patients used SouthDoc Midleton last year. Most GPs saw over 800 consultations with SouthDoc last year, which is unsafe. And 80% of them were routine, ie they did not need to be urgently seen.

“In Macroom, there are nine GPs who cover an area the size of Carlow,

from Ballincollig to Kerry. And six of those nine GPs are closer to retirement than starting out.

“And the GPs that are there can not get anyone to join them because if they worked in the city instead, they would only do a four-hour South Doc shift once every month.

“We’ve had major problems recruiting here, too.

“Midleton, East Cork is lovely. We’re by the coast, we have schools, colleges, a university, an airport, five hospitals on our doorstep, and yet we still struggle to attract GPs.

“We had 27 whole-time GPs in 2005 when SouthDoc started, now we have 30. But the population has gone from about 41,000 to 62,000 and it’s expected to grow to over 80,000 over the next seven years.”

Dr Thompson said that just 2% of GPs who qualified last year want to work as single-practice doctors — a reasonably common setup in more rural areas. This trend he said will ultimately centralise GP practices, forcing rural dwellers to travel increasing distances to access care in larger hub practices.

“I think your idea of a local GP is gone,” he said.

“In the same way as the local Garda station, post office, pub have gone.

“But in times of crisis — like today — who do we look to? A GP.

If general practice is not actively supported and nourished and cherished, it’ll be gone. And it’ll be too late.

But he said that the big message now is to get through the Covid-19 crisis together as a country first.

“This is definitely a national crisis,” he said.

“Socially, economically it’s going to be very challenging for people. I think we’ll see field hospitals set up, GPs out in the community, nursing homes being changed into treatment centres.

“Hospitals will have very serious decisions to make, appointing who to give critical care to. That’s already happening in Italy.

“But the Government here has done everything right, unlike in the UK. And we’ll be here to treat the people who are sick. General practice is here, we’re open and no one will be left unattended.

“While this is very difficult time, I think there will be learning opportunities from it. But let’s get through it first.”

No doctor to see you

Families are being left without GP care in commuter-belt towns and rural areas across Ireland due to an ever-worsening GP shortage.

Currently 26 communities have no GP and . Wwith 700 doctors due to retire in the next five years and without enough graduates to fill those posts, the crisis looks set to deepen.

Some 70% Almost three quarters of general practitioners outside of Dublin are already at capacity and are not taking on new patients.

Dr Maitiú Ó Tuathail, a GP from Connemara who is currently based practicing in Dublin, is concerned that if change does not happen soon, rural general practice will become a relic of history, disappearing along with the local post office, Garda station, and village shop.

“Seven hundred GPs are due toretire in the next five years, that’s 1/4 a quarter of all GPs, and we’re only churning out 90-100 full-time recruits each year,” he said.

“So even if every single GP of the 90-100 continued to work in general practice, we’re still a minimum of 200 GPs short. There were 156 advertised GP posts when I looked recently, and there are 26 communities without a GP — which means that the GP has retired and has not been replaced.

“There’s an impending crisis — huge swathes of the population will have no GP in the next five years.“In Cork, GP practices are needed in Cobh, Youghal, Bandon, and Macroom. So that’s four out of the 26 just in Cork where GPs have retired and have not been replaced.

“In Macroom, if patients want to see a GP they generally have to go to Cork City — about a 40-minute drive. We know that 70% of all GP practices outside of Dublin are now at capacity and are not taking any new patients.

“The distribution of that is very unequal. So that includes every GP in the county of Monaghan, it includes every GP in towns like Ashbourne, Naas, Navan, just to use three examples. It exerts huge pressure on the capacity around the commuter belt.”

These commuter-belt towns, where young families are flocking to buy newly-built houses, are where the GP crisis is most keenly felt.

“If you buy a house in Navan or Naas or Ashbourne in the morning, you will not have a GP in that town, no way. Because all those GPs are at capacity,” Dr Ó Tuathail said.

“If I was born in Naas and I lived in Naas forever, I would have a GP because I’m ahead of the curve. But if I moved to these areas I would not be able to register with a GP. This isaffecting young families who move to these areas disproportionately.”

And he said that the same thing is happening in Macroom, Co Cork.

“GPs in Macroom are also at capacity and this is where the young families are going, because the housing is cheaper. That has a huge effect on families.

“If you don’t have a GP, you cannot vaccinate your child. And if a child in Macroom has a fever, they have to be driven into Cork City to be seen.

“Five years ago, that was really unusual, but it’s quickly becoming the norm around Ireland. It’s a scary place to be.”

He said that the current GP contract — which obliges GPs to provide 24/7 care 365 days a year — is preventing recruits from taking up GP positions in Ireland, particularly in rural communities where the burden of out-of-hours care is more onerous as it is shared between fewer and fewer doctors, while demand has increased.

“The current GP contract is 50 years old. So it’s totally outdated. It refers to doctors as ‘he’ for example, and it doesn’t meet the needs of GPs or, more importantly, of patients, today.

“The health minister (Simon Harris) said that they’ve agreed this new GP contract, but they haven’t. The current contract is the exact same. What they’ve done basically is to pay GPs to do more work. GPs weren’t getting paid to provide care for patients with heart failure or COPD or diabetes.

“What the ‘new contract’ is is an addendum to the old contract which allows GPs to get paid for providing care for these chronic conditions. The core contract hasn’t been touched at all in 50 years.”

Dr Maitiú Ó Tuathail, a GP from Connemara who is currently based practicing in Dublin

But the solution, Dr Maitiu Ó Tuathaill says, is simple.

“Look at the countries where GPs are going to work. It’s in Canada, Australia, and the UK. GP pay is actually lower in the UK than in Ireland, so people are leaving because of the work conditions.

“Only 90 of the 2,500 GPs with a GMS [public patient] contract are under 35. And that’s because younger GPs are not signing up to the contract, largely because it requires you to provide care 24 hours a day, seven days a week, 365 days a year.

“Other countries like the UK,Canada, Australia, abandoned that contract 30 years ago. They differentiated between providing GP care between 8am and 8pm, and urgent GP care after that.

“So in the UK, GPs have two contracts, you work as a regular GP from 8am to 8pm, and then emergency out-of-hours is optional.

“If you’re a 34-year-old GP with two kids who’s working three days a week, the idea of signing up to a contract which requires you to provide care on a 24/7 basis, 365 days a year is going to be scary and unappealing.

“Because you need to organise cover. In Dublin, that’s easy and in Cork you have SouthDoc, so if you’re in Cork City, you become a member of SouthDoc and you do one weekend every six weeks and maybe one night shift every six weeks.

“But when you move outside of Cork, in West or East Cork, that commitment changes hugely, so in Bandon for example, or Youghal, you might do one evening every week and one weekend every three weeks.

“You can’t raise a family if you’re going to be away every third weekend and on call at least one night a week.

“So GPs are not taking up those jobs, they’re looking for jobs instead in Blackrock in Cork City or Blackrock in Co Dublin. But they’re not looking for them in rural areas because of this contract issue.”

Dr Ó Tuathail said that increasing the percentage of the health budget paid to GPs is also central to improving healthcare in Ireland.

“Twenty years ago in New Zealand they were where we are today. They had people on trolleys. Waiting lists were not as bad as ours, but they had huge issues. And they basically made the decisive change to move away from this hospital-led model of care.

“But in the UK and New Zealand they figured out that the more you do in GP practices, the cheaper it is.

“They started increasing the proportion of the healthcare spend on GPs and they reached 8% in the UK and 10% in the Netherlands and they saw huge improvements in waiting lists, trolley figures, and the number of GPs.

“They have twice the number of GPs in Australia, Canada, and the UK and they don’t have the trolleys or the waiting lists.

“But in Ireland, just 3.5% of the overall healthcare budget is spent on general practice and everything happens in hospitals.

“You have to get all your scans in the hospital, all your minor surgery in the hospital, everything happens in the hospital.”

The Government hopes to implement Sláintecare, a 10-year plan with wide cross-party support, which would make general practice even more central to the health service and which would make healthcare universally accessible.

But to fulfil this plan, more GPs are needed.

Dr Ó Tuathail said: “The plan for Sláintecare is that we can move towards the Netherland’s model where 10% of the healthcare budget goes into general practice. But we’re nearly three years into that and we’re at 3.5%.

“Meanwhile, more and more money is pumped into the National Treatment Purchase Fund because the headlines say ‘Waiting times in A&E and trolleys’.

“And the quick fix for that is to put money into the NTPF to open up private hospital beds. But that’s a short-term solution.

“What they actually need to do is increase the proportion of the healthcare budget that’s spent on general practice to prevent so many people from having to go to hospital in the first place.”

A spokesperson for the HSE said that as of March 1, there were 24 vacant GMS panels with almost 3,000 GPs in place nationally.

These vacant panels represent less than 1% of GMS panels and cover is arranged to maintain services in the communities until the vacant panel is filled, it said.

Macroom GP crisis

Newcomers to Macroom, a growing town in Co Cork county, may be have been able to find a home there despite the housing crisis, but they face another shortage — the GPs cannot take new patients into their practices.

Demand for GP care there is so chronic, that Dr John O’Riordan, a local GP, has been unable to take on new patients, either public or private, for approximately five years now.

People living in Macroom may now have to travel 60km to see their GP, an issue raised in the Dáil last year by Cork North West Fianna Fáil TD Aindrias Moynihan.

“One of the local doctors retired last September and they have not been able to fill his list,” Dr O’Riordan said.

“One of our GPs is going on maternity leave soon and she’s been unable to source maternity cover. Her husband is in the same practice and it looks like he’ll just have to manage — even though he’s already extremely busy and working at capacity.

“We’re a group practice, we usually have locum cover when a doctor is away. This is the first year that we’re finding it impossible to find someone to cover us.

“It’s ironic that when you really need your time off you’re not sure whether you will get it. You’re conscious you’re putting an extra burden on your colleagues if you take it.”

And the spectre of retirement is not just scary for patients, but forfellow GPs too.

“I’m in a practice where my colleague is close to retirement and I’m looking down the barrel of a gun, really.

“If he retires in the next year or two, he can’t be replaced, and I’m having difficulty coping with the workload as it is, so I dread to think what would happen if he retires and there’s no one to take his place.”

The pressure of the GP shortage is felt most acutely in rural Ireland.

“Rural GPs are suffering more than in cities and bigger towns because we have more onerous out-of-hours duties and we’re finding it impossible to attract young GPs,” said Dr O’Riordan.

“They want a proper work-lifebalance and they’re just not going to work the weekends or the long hours that rural GPs are used to working.

“I was here at 8am. I’ve been here for 10 hours today. I’m on call this evening so I’ll be in South Doc until 10pm at least and possibly 11pm, it’s a long day.

“And that happens one in nine days. Then we do weekends that involve 14-hour shifts, that’s one in nine weekends.

“It’s not sustainable in the long term.”

Dr O’Riordan is “hoping” that things will change soon.

“Sometimes you have to reach crisis point before people start making decisions that will rectify the situation,” he said.

“There has to be a radical overhaul of the out-of-hours system and the way it works.

“We need fewer out-of-hours centres and better co-operation between rural and more urban GPs to even out the out-of-hours burden.”

Although the HSE is trying to provide temporary GP cover in Macroom on Sundays, Dr O’Riordan said that getting locum doctors to cover the red-eye shifts — at nights and weekends — has been difficult. So although there is cover some Sundays, you doctors do not know whether there will be until shortly before the shift, so pre-planning anything on a Sunday is difficult.

“We’re a training practice, we get a different doctor every year. A lot of them really like working in rural areas, but the out-of-hours issue is what’s preventing them taking jobs in places like Macroom.

“The writing’s been on the wall for a good number of years, but nothing has changed.

“We need to make it attractive to GPs who’ve gone abroad to come back, and we can only do that by assuring work-life balance.

“I would like to ask Simon Harris to acknowledge that there is a crisis. And that things need to change. Rejigging the GP contract and pretending everything’s OK will not work.”

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