“You’d get an appointment with a vet quicker,” is a comment often heard these days, but what’s behind that difficulty and do we understand all the nuanced problems that have led to such dissatisfaction with the service?
Burnout is the number one issue, caused by the double whammy of increased workload and GP shortage, doctors say. That means that doctors can’t get enough time off to have a rest, take holidays or attend seminars or family events. Verbal abuse of practice staff has become common too, due to patients’ difficulty in getting appointments when they want them.
“COVID has played havoc, but burnout among doctors is the big issue,” says Dr Jerry Cowley, chair of Rural, Island and Dispensing Doctors in Ireland (RIDDI).
Speaking with him on a bank holiday evening, he had been catching up on paperwork all day, doing things like writing a medico-legal report related to a patient who had an accident and filling in forms related to applications for carer’s benefit.
“You don’t have time to do that during the working day,” he says.
“Doctors now seem to spend weekends and nights and holidays trying to catch up with book work. The elephant in the room is that GPs can’t get away anymore. There is just a lack of doctors and not enough locums. In the past, doctors in rural areas often worked until they dropped. Younger doctors are not prepared to accept that. They want time off and quality of life.”
The President of the Irish College of General Practitioners (ICGP), Dr Paul Armstrong, agrees.
“GPs are experiencing a huge increase in workload since the pandemic, while unable to fill vacancies when colleagues retire, or fill a new post because of demand.”
Munster-based medical secretary Clare sees GPs’ workload first hand.
“The amount of work that GPs do behind the scenes that patients don’t see is phenomenal. The GPs in my practice work 12 hours a day and could still have work to do in the evening. They have to go through every letter, blood test, x-ray and MRI result that comes in and they’ll have follow-ups from that.”
How many GPs do we have and how many do we need?
There are approximately 3,500 GPs practising in Ireland. This includes 2,500 who hold a GMS contract, which is the medical card contract, 540 GPs who hold other publicly funded contracts (such as primary childhood immunisation and maternity and infant care), and a further 500 working outside of publicly funded contracts.
“This is an average, therefore, of 0.69 GPs per 1,000 population when we require 1.1 GPs per 1,000 population,” according to Sinn Fein TD, Seán Crowe, the chair of the Dáil Committee on Health last January.
Also, the distribution of GPs is not uniform. Some areas of the country have a much lower ratio of GP per 1,000 population.
In relation to retirement, some 700 GPs are due to retire in the next six years, according to the ICGP.
“At least 2,000 new GPs will be needed within the next seven years to meet existing demand,” they say.
Two-hundred-and-fifty-eight doctors entered training this year, up from 233 in 2021; still well short of what’s needed.
There are currently too few GPs in Ireland to meet demand, with rural Ireland particularly affected as rural practices are not deemed attractive by graduates.
From the map you can see that counties Galway, Mayo and Roscommon have seven vacancies for medical card doctors, as have counties Kilkenny, Carlow, Tipperary South, Waterford and Wexford. The Cork/Kerry region is well served with zero vacancies, as is the Dublin South and Wicklow area.
Why GPs are not choosing rural practice:
“Doctors in rural Ireland are retiring and no one wants the job because of the lack of supports,” says Dr Cowley.
The pandemic has caused a huge increase in workload and stress for GPs and practice staff.
“Since COVID started, there is a lot more involved in the job from every aspect,” says medical secretary Clare.
“There is a lot more admin and we are dealing with a lot more patients who are sicker and, through COVID, patients have become less tolerant and more demanding.
“When the vaccines came in, the ante was upped completely. Many people were really demanding their vaccine. It made the job of working in a medical centre very, very stressful.
“At the end of last year, it was ferocious. There are nine medical secretaries in this practice and there wasn’t a week went by that there wasn’t someone in tears because of the abuse they got from patients. It was unbelievable, to be honest.
“Recruiting new GPs is very difficult too, when someone retires, moves away or goes on maternity leave.”
Chronic illness management
There are other general pressures on GP practices too as more and more responsibility for chronic illness management has been given over to them.
“Diseases are more complicated, prevention and medico-legal issues more complex, but the systems are not yet set up for it,” say the ICGP.
Free GP care for the under-6s has also increased GPs’ workload (and now free under-eight care will soon come on stream). So, too, has more people relocating to rural areas during the pandemic and needing to register with GPs. Ukrainian refugees needing care since February has also meant greater need for GP care in rural Ireland.
Hospital waiting lists
One issue that Stephen McMahon of the Irish Patients’ Association (IPA) sees evidence of is the impact of big waiting lists on GPs’ workload.
“The western seaboard has huge public waiting lists for treatment,” he says. “Those patients are waiting so long they are constantly going back to their GP ... That’s putting a huge extra workload on GPs. The waiting lists issue needs to be sorted.”
Many doctors complained to Irish Country Living of having to do too much out of hours work. This is quite different to urban areas, they say. “City doctors don’t have to do evening or night-time shifts whereas many rural GPs are obliged to. This can involve working overnight and then doing a full day’s work afterwards.”
Not having access to patients’ medical records during out-of-hours periods is also a stress for doctors and patients and their families, if the cases are complicated.
This was highlighted in the recent Health Information Quality Authority (HIQA) report calling for the establishment of a citizen health portal to provide the public with access to and control over their health and social care information.
General practice underfunded
Does it all come down to money and doctors wanting more of it? Are they just whingers or do they have a case?
Money (aka supports and resources) being needed is mentioned a lot. FEMPI (Financial Emergency Measures in the Public Interest) cuts of 38% for GPs during the recession are still a sore point. While they have now been restored, the underfunding over many years has had an effect, doctors say. Increasing costs and patient demands and expectations are still highlighted.
“The rural practice allowance was also cut, along with distance code payments. It costs a lot to run a surgery so it can come down to viability, we [IPA] were told. Not every practice can afford valued help in the form of a practice nurse, for example.”
Many doctors regard the Irish health service as dysfunctional and believe that this is forcing doctors to emigrate in search of a better work-life balance, better facilities and faster turnaround times for tests and treatment for patients.
“It’s not just about lifestyle and money. The waiting lists here are soul-destroying. In the past, many came back after getting valuable experience abroad, but now many are staying away for the reasons mentioned above.”
Stephen McMahon puts down a marker about this, however: “We have to be careful here, there is so much negative talk about what’s going on in our health system that it’s feeding a negative perception for people who are going to start working in it. They may think ‘far away fields are green’ but they have their own challenges, own pressures and stresses in those facilities (abroad).”
As at 1 August 2022, there were over 2,500 GMS GPs in place nationally with an additional circa 540 GPs who, while not holding a GMS contract, do hold other publicly funded health sector contracts with the HSE. There are 25 vacant GMS panels with just over half of these vacancies based in rural areas. These vacant panels represent less than 1% of GMS panels, and cover is arranged via a locum or other appropriate arrangement to maintain services in the communities until the vacant panel is filled. The map illustrates the list of current location of GMS vacancies by CHO area. The number of GPs aged 65 years and over is 290, which represents approximately 11%. (HSE)
Indeed.ie shows that the average income of GPs is: €57,804 per year in Ireland
Some examples include €124,800 in Limerick, €83,000 in Balbriggan, Dublin, €79,382 in Clare
65 salaries reported, updated at 21 August 2022.
What a doctor gets paid per year for medical card patients (capitation rates as at January 2022 – HSE figures)
GMS doctors also get paid an enhanced capitation fee for some patients eg those with diabetes €100 (two visits per year).
What GMS GPs were paid in 2020 (published July 2021)
In 2020, over 2,900 GPs across Ireland were paid a total of €788m under the medical card scheme. This includes practice support payments they received from the HSE. Some 24 practices got over €800,000 each - with five getting at least €1m.
However, Monaghan GP Dr Illona Duffy has said that the figures do not tell the whole story.
“The medical card scheme payments are never just a salary to a GP, they’re a payment to a practice and while there may be one GP’s name, that doesn’t necessarily give a true picture of what that money goes towards. As we know, a GP practice is not just the GP - there’s the full team, and that goes from the GP nurses to the receptionists, secretaries, cleaners and obviously all the payments that are required to run a business.”
Next week: The solutions – what are they?