“The government needs to get it together.”

That was a statement from Dr Jerry Cowley, chair of the Rural, Island and Dispensing Doctors Ireland organisation (RIDDI) in relation to solving the GP shortage and attracting GPs to rural Ireland.

In week one of this series, we highlighted patients’ concerns and in week two, doctors’ concerns came under the spotlight. Week three was solutions driven with a “shopping list” provided by stakeholder organisations.

We sent week three’s suggested solutions to Minister for Health, Stephen Donnelly and to the HSE’s outgoing CEO, Paul Reid, for a response.

Did they address the issues? Will what they have to say help us avoid the “abyss of a chronic shortage of GPs by 2025” as mentioned last week by the Irish Medical Organisation’s Dr Martin Daly?

Minister’s response

The Minister is aware of the workforce issues facing general practice, he says.

“The Government has taken steps to increase the number of GPs nationally, and to help attract GPs to rural areas.”

He points out the following improvements under the 2019 GP Agreement:

A 10% increase in payments under the pre-existing Rural Practice Support Framework and

A 28% increase to dispensing doctor fees and that

maximum allowable rates are paid to rural practices for practice staff support subsidies and locum contributions for leave-taking.

He also says that the number of doctors entering GP training has increased approximately 10% year on year from 2019 to 259 this year, ?(the ICGP says this isn’t enough).

He acknowledges that GMS GP vacancies can be difficult to fill, but offers no other comment on this other than that “the HSE actively tries to find a replacement.”

The biggest news from the Minister’s office is probably this – that preparatory work has commenced on a strategic review of GP services to examine how best to ensure the provision of GP services in Ireland for the future.

If reasonable working conditions were restored, everything would be fine as no one wants to work in an area where you can’t get away for a holiday or even a family bereavement.

How long will this take, though? Should communities without resident GPs at present hold their breaths?

Week two of our series has highlighted that this HSE process (of finding replacements) isn’t working as many posts have to be re-advertised due to lack of interest.

No mention was made, either, in the Minister’s response, to the bugbear of the 365 days a year 24/7 nature of the GMS contract putting so many doctors off right now.

As of 1 September, we are told there are still 25 GMS (medical card doctor) vacancies with 50% of those in rural areas, putting rural Ireland at a distinct disadvantage particularly in the west and north Leinster areas.

HSE response: CEO Paul Reid

So, what was the HSE response to the suggested solutions?

“The HSE is committed to engaging with the relevant GP stakeholders in ensuring the sustainability of general practice, and in addressing workforce challenges in this critically important part of the health service,” the CEO Paul Reid says.

The HSE is doing this by supporting GP practices in rural communities, and by investing in GP training in conjunction with the ICGP.

He also points out that rural GPs get a €22,000 a year allowance towards paying support staff and that locums get enhanced expenses contributions.

We asked Dr Jerry Cowley, chair of the rural doctors’ association (RIDDI) to comment on this.

“It is true that practices in receipt of rural practice supports attract the maximum allowable rates for practice staff support subsidies and locum contributions for leave-taking,” he says, “but unfortunately this long-standing arrangement has made no difference to the successful recruitment of doctors to fill those vacant rural practices. They still remain unfilled years later. If reasonable working conditions were restored, everything would be fine as no one wants to work in an area where you can’t get away for a holiday or even a family bereavement.”

The CEO of the HSE said that the continued expansion of GP training is of key strategic importance to the HSE and that arrangement will be made to engage replacement GPs to fill the 46 vacancies that will come about in 2022 because of retirement.

There is no mention of the likelihood of salaried posts being offered to GPs, of waiting lists being sorted or of the grievances of GPs who work overly long hours while training in Irish hospitals being addressed.

The blueprint (or some would say “blue sky”) Sláintecare plan that was published in May 2017 was mentioned, particularly its “objective of policy moving from an emphasis on acute care towards investing in preventative, planned and well-coordinated care, re-orientating services towards general practice and enhanced community care (ECC) services.”

He mentions the €210m that has been provided to general practice for the implementation of the award-winning innovative Chronic Disease management programme.

He also flags the €240m that has been spent on establishing 96 Community Healthcare Networks (CHNs) and 30 Community Specialist Teams for Older People and Chronic Disease Management, which will be accommodated in hubs co-located with ?primary care centres.

It’s all about a population needs approach, he adds, but again the question remains - how long will it all take for patients to have easy and equal access to GPs in rural Ireland?

The international experience

Recruiting and retaining doctors in rural areas is an internationally recognised problem, however? some countries have adopted a multi-faceted approach, as highlighted in week three’s solutions.

The World Health Organisation suggests four categories of intervention – educational, regulatory, financial incentives and professional and person support.

Australian research has shown a strong association between selection of students with a rural background and increasing the supply of Australian rural doctors. Extra financial incentives are also offered, such as infrastructure and relocation grants.

In the USA, a Pennsylvania medical college targets medical students from rural backgrounds, for example, and gives them financial incentives and rural placements to develop their skills.

The French government provides a package of incentives to encourage doctors to practice in rural and underserved areas also, including training initiatives, financial incentives, development of telemedicine and developing infrastructure in isolated areas including access to emergency care.

€355,000 spent on locums from Achill since early 2021

Locum cover (stand-in GP) costs were mentioned as a waste of substantial taxpayers’ money in week two.? While the HSE response makes it sound like all that can be done is being done when there is a vacancy, this story from Achill makes startling reading.

There has been a vacancy there since January 2021 and the HSE confirmed to The Mayo News recently that €355,000 has been spent on locum GP care there since that time. Dr Jerry Cowley described the amount as “flabbergasting”.

“The result is that these rural practices still remain unfilled to this day with a HSE supplied locum providing the service commonly costing the taxpayer multiples perhaps of what it cost to run the same practice originally.”

His stance is that two doctors, not one, should be appointed to isolated areas, something that would cost less than this private agency run situation.

it’s unfair that people must look for lifts to see the doctor, especially on a regular basis.

What can patients do to help during GP shortage?

How do you know for sure that you need a GP appointment?

Northern Ireland’s 3BeforeGP campaign suggests doing your research about your symptoms on reputable websites like NHS Choices (or the HSE website) and perhaps consulting a pharmacist before making that call to the doctor. https://www2.hse.ie/under-the-weather/ is a good website when trying to figure out what winter illness will require an antibiotic and what won’t, for example.

We’ll leave the last comment about this to Clare, the medical secretary, mentioned in week one, who said that not a week went by in her practice without a staff member being in tears because of abuse from patients.

“We would ask patients to be patient and to respect the staff,” she says. “Everyone is trying to do their best. We worked continuously during COVID and put ourselves on the line and we would ask patients to respect that.”

She also provides more insight into her job.

“You’ll have regular offenders who’d drive you off the head and offenders who DNA [do not attend] their appointments too. You could have a few of those every day, which is highly frustrating when you’re so scarce on appointments.”

Through the pandemic, patients have become less tolerant and more demanding, she adds.

“When the vaccines came up, 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. Some patients are serial abusers who will be offensive all the time, but COVID brought it to a new level.”

Patients for patient safety Ireland

In week one, a farmer who took issue with out of hours care (“If you’re going to be sick out of hours, be a cow!”) mentioned that medical records should be available to out-of-hours doctors so that family members don’t have to keep remembering and explaining the patient’s medication list.

While medical records are not available as yet in these situations, the Patients for Patient Safety Ireland group has a useful tip in the meantime.

“Our message is simple,” says spokesperson Bernie O’Reilly. “Keep a medication list to hand, not just of your prescription meds but anything you take on a regular basis for health reasons.

“The list is for your own use when engaging with any healthcare situation where you are asked about your medications. It will be a back up to relying on memory alone and will be there in emergency where a person can’t give the details themselves.”

Last word

We’ll give the last word to an ICA group in West Wicklow. Asked for their opinions of access to GPs, Mary Manley, on behalf of Donard branch, had this to say:

“Donard is a rural village in west Wicklow. We have a lovely health centre here, which is lying idle since COVID. Prior to that, a GP and nurse visited for a few hours once a week. This means that patients from Donard and The Glen of Imaal, which is a large and widespread area, must get to the health centre in Dunlavin, which is five miles from Donard and another five from parts of the Glen. Not everyone can drive or has access to a car between 9am and 5pm and it’s unfair that people must look for lifts to see the doctor, especially on a regular basis.”

Read more

Investigation Part 1: Doctor shortage causing strife

Rural healthcare: doctors under pressure