The changing face of general practice

For general practice to work at its best, it needs to provide a wide range of care

GP is not a protected term. Many services provided by general practitioners are also offered by medically qualified doctors working in the many walk-in private networks that have appeared throughout the country. Such doctors are available online 24/7 or in person, both in- and out-of-hours. They may or may not have completed recognised specialist medical training and are not required to be on the specialist division of the register. These doctors provide immediate care for single-issue problems and advise returning to ‘your own GP’ if your problem persists or evolves. There is no shortage of doctors willing to provide these services, and, understandably, patients will use them when their own GP cannot provide a timely consultation.

Most people associate the title GP with a doctor who provides continuous care for all types of problems, acute and chronic presentations, antenatal care, childhood vaccinations, and cervical screening, to name a few. Doctors who provide this type of care are in short supply. The reasons for this shortage are varied: Population growth, ageing patients with more complex diseases, GPs nearing retirement, and younger GPs unwilling or unable to set up a practice because of the onerous workload and cost.

Patient expectations have increased in recent years.

Single-agenda consultations are rare and every encounter results in at least one action to be done later. Every GP session runs over and every GP I speak to does additional non-face-to-face sessions in the evening or on the weekend to catch up on blood results, referrals, or hospital reports. It is not surprising that younger doctors are thinking twice before taking on the increasingly onerous task of running a general practice.

The workforce problem is not new. We have known this for some time and have implemented various strategies to address it. The HSE and Irish College of GPs (ICGP) have worked together to increase the number of places on training programmes. But it takes at least four years to train a GP. It takes longer when the training period includes maternity or sick leave. So, this is at best a longer-term solution.

The International Medical Graduate Rural GP Programme was devised to identify and train suitable doctors to integrate into rural general practice. This two-year programme is supported by the ICGP, HSE, and medical indemnity organisations, and some graduates are already in practice throughout the country. These measures are welcome, but not enough.

In the first half of last year, 6,000 people contacted the HSE to say that they could not get a GP to take them on. Figures for patients who cannot obtain a timely appointment with their GP are harder to find. A very small study of 80 patients attending an out-of-hours service in the south east found that 36 per cent were doing so because they could not get an appointment with their GP. Most patients who attend online doctors or walk-in private clinics do so for the same reason.

All over the country, these single-issue consultations are seeping out of general practice. At the same time, the GPs’ days are filled with older patients who are sicker and have chronic disease, multimorbidity, and polypharmacy. Even younger, healthier patients rarely attend with one problem that a GP can manage effectively in 10 to 15 minutes. For doctors, this is a fast track to burnout. It is also not good for patients. A good doctor-patient relationship requires a mix of high- and low-stakes consultations. When a doctor knows their patient well, it is easier to spot deviations from normal and recognise the signs of serious disease: The older woman who suddenly starts missing her appointments; the young mother who snaps at her child.

This is how general practice should work. That is, to provide continuous care, acute and chronic disease management, alongside illness prevention, with a little spare capacity for urgent care. The GP should be the first point of contact for patients who have acute problems, and we need to advocate for the right strategies and investment to retain this portion of general practice.

Last week, a woman I had not seen for a long time limped into the consulting room. She rummaged in her bag, pulled out a list, and read it: Menopause; blood pressure; osteoporosis. On and on, it went. I waited for her to mention pain in her leg, hip, or knee, but she didn’t. When she finally put the paper down, I asked her why she was limping. “Oh, I didn’t want to bother you with that,” she said. “I got sorted out at the Vhi SwiftCare Clinic a few days ago. But you can have a look at it if you like.”