Keeping alive the success story of general practice

Niamh Cahill speaks to new ICGP President Dr Paul Armstrong about the workforce crisis facing general practice, but also the progress that has taken place at a challenging time.

It is a critical juncture for Irish general practice. Increased retirements are on the horizon, recruitment problems continue, and workload challenges abound. 

Currently, there is an inadequate number of GPs and an even greater shortage is feared, as 25 per cent are aged over 60 and will retire in the next decade. 

The HSE has predicted a shortage of around 1,660 GPs by 2028. 

This, among other factors, has left those within the profession gravely concerned about its future. If the situation is not addressed “all the success stories of where we’re doing well will be lost”, Dr Paul Armstrong, President of the ICGP, told the Medical Independent (MI). 

Dr Armstrong, a member of the College since 2014 and a GP Trainer in the Donegal Training Scheme, took over as President at the ICGP’s Annual Conference in June, replacing Prof Tom O’Dowd in the position. 

Dr Armstrong assumes the role at a time of not only great change for the College, as the transfer of GP training from the HSE concludes, but at a turning point for general practice. 

Workforce crisis 

For months, the College has been seeking a meeting with Minister for Health Stephen Donnelly on the establishment of a high-level working group to address problems facing the profession. However, at the time of going to press, these pleas remained unanswered. 

In the next seven years 2,500 more GPs will be required. Current GP trainee numbers will not meet this demand (258 places were offered to trainees this year). 

It is planned that annual GP trainee numbers will reach 350 by 2026. However, the population is increasing and people are living longer, which needs to be considered in terms of recruiting additional GPs and primary care healthcare professionals, Dr Armstrong pointed out. 

While GPs deliver around 30 million daytime and out-of-hours consultations annually, it is not sufficient to meet demand. Ireland has 30 per cent fewer GPs per head of population than England, which itself is facing challenges with regard to the delivery of primary care. 

Furthermore, around 25 per cent of all GPs in Ireland run single-handed, often rural, practices. To compound matters, there is also a practice nurse shortage. 

If solutions are not found, it is feared more and more patients will be unable to access GP care. Such a scenario would be unthinkable given the pressures secondary care services are under. 

“We need to address this,” Dr Armstrong told MI. 

“We can’t leave our head buried in the sand, which appears to be the political approach at the moment. There is a workload crisis and it’s going to get worse. The figures are there. They’ve been known for some time… the maths on this are pretty stark. 

“We know colleagues are having problems finding replacements in rural and urban practices – not only in single-handed practices, but group practices. This is happening and all the success stories of where we’re doing well will be lost if we cannot continue to provide services.” 

The College has collated workforce data and is preparing a paper aimed at emphasising the gravity of the situation to Government. 

The absence of any meaningful response from Government is frustrating, the Lifford-based GP conceded. 

“We are disappointed. We’ve written to him [Minister Donnelly] several times and apart from a cursory initial response we’re still waiting.” 

The experience of other jurisdictions is an added worry for GPs. 

In Northern Ireland, close to Dr Armstrong’s practice in Co Donegal, several practices have no GPs at all, and five-minute appointments are the norm. 

“The UK is facing a greater crisis, but we are going that way unless we see the writing on the wall and change direction,” he warned. 

Around a dozen communities nationally are without a permanent GP. When gaps occur the HSE is forced to employ temporary doctors to maintain services. Many GP practices are closed to new patients and have been for years, as they cannot take on greater workloads. 

According to Dr Armstrong, single-handed, often rural, GP practices can be unattractive to young GPs as they lack support structures. 

We can’t leave our head buried in the sand, which appears to be the political approach at the moment 

Concerns exist around solitary working and remoteness. It has been shown that doctors prefer to work within a support structure that offers holidays and time-off when ill. 

“Sometimes the lists just aren’t viable to a GP trying to make a living and employ staff in a practice,” he added. 

“There is no such thing as a solo practitioner anymore. It’s not something that is sustainable. You need a colleague, you need a sounding board, time off and that can’t be provided if you’re working alone, no matter how remote you are.” 

WONCA meeting 

The problem is an international one and was discussed at the World Organisation of Family Doctors (WONCA) 19th World Rural Health Conference held in the University of Limerick in June, which was aligned with the ICGP’s own annual meeting. 

The 5,000 worldwide members of WONCA work to improve healthcare in rural communities. Hundreds gathered to discuss challenges in providing rural healthcare, with an emphasis on empowering rural communities to improve their own health and wellbeing. 

Such initiatives are welcome, but it is equally important GPs are supported to help improve the health of their patients. Dr Armstrong stressed that solutions exist. 

“They involve innovative thinking and resources and some type of funding to allow that to work… these problems are universal and there are solutions.” 

Before taking up the role of President, Dr Armstrong contributed to the College in several capacities, demonstrating a desire to help improve GP education and development. 

He served as Chair of the education committee and Chair of the quality and standards committee. He has represented the ICGP in the University College Dublin Centre for Emergency Medical Science and the Irish Health Services Accreditation Board. 

Combined with his medical skills, this experience has provided him with an acute understanding of the needs of general practice and its patients. 

Chronic disease 

The HSE chronic disease management programme, introduced in 2020, has enabled GPs to improve the health of people with chronic disease. 

The Executive published the first report on the programme in August, which highlighted that 91 per cent of GPs are taking part in the programme. 

It is being rolled out to adult patients over a four-year period and has a target uptake rate of 75 per cent. It is estimated that around 430,000 patients with chronic disease, or at high risk of chronic disease, will be registered when the programme is fully implemented in 2023. 

The development was part of the GP agreement negotiated by the IMO and Department of Health in 2019. It includes GP and practice nurse visits for all public patients, as well as opportunistic case finding and prevention for public patients aged 65 and over. 

The chronic diseases included are type 2 diabetes, asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease. 

According to the HSE, the programme supports GPs to identify and manage patients who have a medical card or doctor visit card and who are at risk of chronic disease or have been diagnosed with one or more of the specified chronic diseases. 

It focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity, and the provision of care as close to home as possible. 

In Dr Armstrong’s Donegal practice, which has 10,000 patients, hundreds are being managed through the programme.

This has led to a large increase in workload. In response, Dr Armstrong has taken on a phlebotomist, increased nursing hours, and dedicated more GP time and sessions to the programme. 

The outcome has been positive for patients, whose care is actively monitored, while opportunistic case finding on individuals with risk factors has proven beneficial. 

The programme is an example of one of the “positives” Dr Armstrong is keen to focus on within his profession. 

“The health service, for all its inadequacies, actually delivers very well,” he told MI. 

“We have a very effective chronic disease model for patients. It is putting practices under pressure, but the reason we’re doing it is because it works. People are living longer healthier lives and they have higher expectations. 

“Because of the pressures we tend to look at the negatives. But I think we need to look at the positives and the achievements from within general practice; the amount of work that we do. Its ability to deliver during Covid was exceptional, but the corollary of that is we have to recognise it brings pressures and we need resources, planning, and personnel for that.” 

Diagnostics 

The crisis period has abated, but the health service is still experiencing the negative effect of Covid-19. 

One practical way that care was enhanced because of the pandemic was the development of a diagnostic referral channel for GP patients requiring ultrasounds, x-rays, MRIs, and CT scans, according to Dr Armstrong. 

The local hospital (Letterkenny University Hospital), he said, was struggling to meet demand for such services before the HSE engaged a private provider locally to undertake investigations. 

A similar system is in place nationally and has relieved pressure on hospital services. 

“There is reasonably good access now. Waiting times are getting longer as more people are referred into it, but certainly prior to this we had no access for medical card patients for MRIs or CT scans. That has changed. 

“We are finding things and picking them up and referring them into the hospital system. That has definitely expedited investigation for a lot of people.” 

Consultations 

The nature of GP appointments transformed during the pandemic as consultations became remote, often undertaken via telephone or video. 

Most GPs have now returned to standard “face-to-face consultations”, Dr Armstrong said. 

Around 80 per cent of Dr Armstrong’s appointments are now conducted in person and this is the case in most practices, he said. GPs are also conducting house calls, he added. 

Furthermore, in an effort to respond more effectively to the needs of patients and improve patient care, GPs are offering longer consultations. 

Nationally, GPs consultations were perceived as being too short, but GPs are providing longer appointments following patient requests, according to Dr Armstrong. 

“This varies from practice to practice, but it would be pretty much the norm that appointments would be 12 or 15 minutes long or even 20 minutes. It creates extra need too because you become aware of other issues. 

“Traditionally, in some areas of general practice you had five- or 10-minute consultations. Most of us are moving to 15- or 20-minute consultations. In those consultations you do become aware of a wider range of problems; that’s the reason we’re doing them. You are aware of psychological stressors people are living with and how it affects their health.” 

In the UK, he said, general practice is struggling with shorter, often five-minute, consultations. 

“But in Ireland our appointments, certainly at our practice, have gone out to four per hour.” 

Mental health 

Longer appointment times are of particular benefit to GPs when faced with complex areas, such as mental health. 

The pandemic had an immense impact on mental health, the effects of which are being seen daily by GPs. 

Anecdotally, there has been an increase in the number of people with mental health problems since the crisis. 

“It affected people individually in reducing socialisation and mixing and people found this very difficult to cope with over the two years. This moved beyond loneliness to people having significant symptoms of anxiety and depression,” said Dr Armstrong. 

“A lot of these issues are only now coming to the surface, as during Covid they were often supressed.” 

For patients who need extra support beyond what can be offered by their GP, accessing services is extremely difficult, Dr Armstrong explained. 

Initially, when patients were referred to counsellors or clinics they were treated remotely, over telephone or video. 

“This wasn’t terribly satisfactory and was difficult for people,” said Dr Armstrong. 

Even now, accessing one-to-one care is challenging. 

“Access can be slow in getting appointments and typically that all lands back on the GP’s desk… mental health services are under huge pressure and it will need significant resources.” 

Burnout 

The health of GPs has also come under significant strain. When Covid-19 emerged, GPs were catapulted into a healthcare emergency necessitating even longer working hours and larger workloads. 

Two years on and GPs are still struggling to find temporary doctors so they can take time off when sick or for holidays, according to Dr Armstrong. 

He said that burnout is “a risk for the profession and for people running on empty”. 

“It’s an issue for many people who feel that their days are getting longer and the demands greater. If we could get the politicians to engage and address the seriousness of problem we will reduce the factors which contribute to this.” 

ICGP support 

Immense support to GPs was provided by the College throughout the pandemic. The weekly Wednesday Zoom meetings were a particular success, offering not only information, but advice and guidance to GPs on issues associated with Covid-19. 

These meetings will continue “once or twice a month” as continuing medical education (CME) or small group learning has now recommenced nationally. 

A lot of these issues are only now coming to the surface, as during Covid they were often supressed 

CME meetings will run in parallel with national meetings, Dr Armstrong said. 

The administration of Covid-19 booster vaccines is continuing in practices and Dr Armstrong anticipates that GPs will commit to delivering more vaccines, including the influenza vaccine, in the autumn. 

The complex process involving the transfer of GP training from the HSE to the ICGP and the introduction of a new model of training is almost fully complete. 

Almost all programme and assistant programme director posts have been filled. The budget was transferred to the ICGP in July. The College is now fully responsible for both the delivery and supervision of standards of GP training. 

Ultimately, Dr Armstrong believes there is much to be positive about in general practice, despite the challenges it faces. 

“It [GP] is a good job, a good career, and is hugely rewarding on a personal and professional basis. 

“In the job you try and represent the College and colleagues and influence decision-making at a political level and represent people as best you can. We’re patient advocates and often we get frustrated, as you’re dealing with hospitals and waiting lists. But it’s what we do and we do it with a heart and a half.”