With an ever-increasing number of clinical guidelines to improve patient care, there are concerns about the impact on GP workload and resources. Niamh Cahill reports
Medicine is a field where developments and improvements occur constantly. The production of clinical guidelines for GPs on various health conditions is part of this progress.
According to the Irish College of GPs (ICGP), clinical guidelines help healthcare professionals to make the best decisions about treatment. As treatments evolve and improve, guidelines are intended to support GPs in delivering the best patient care.
However, according to Dr Austin Byrne, a GP in Waterford, a growing tension is emerging between the expectation for GPs to meet ever-rising standards and the limited funding available to support these advancements.
“This is an inevitable consequence of the need for progressive practice in an environment that is increasingly complex and increasingly changing with pace,” Dr Byrne told the Medical Independent (MI).
He is among a number of GPs who believe there has been a noticeable increase in the volume of clinical guidelines produced in the last number of years. This increase comes at a time when general practice is becoming more demanding, particularly with the pressures of a growing and ageing population.
Concerns include a persistent shortfall in State funding, which many GPs argue is essential to keep up with clinical progress. Another source of unease is the medico-legal implications of new guidelines and their impact on workload – especially in the context of an ongoing GP shortage across Ireland.
The introduction of more clinical guidelines and general practice updates (GPUs) – which often run to dozens of pages – is a somewhat recent phenomenon for general practice and has arisen alongside developments in preventative care in the specialty, according to Dr Byrne.
“I’m at this desk 15 years now and in the decade before I started here preventative care was almost non-existent,” he said.
“Preventative care for cardiovascular disease didn’t really take hold in Ireland until the early 1990s. It was the mid-1980s when it gained ground and in the early 90s it took off.”
He also pointed to heart disease as an example of how treatments have evolved, noting that stenting – now commonplace – was not an option in the 1980s.
From the 2000s onwards, stents became standard, and patients who received them often went on to live full lives, supported by multiple medications and regular follow-up care.
Dr Byrne said the level of care involved in managing other conditions has also grown dramatically over time.
“It hasn’t gone up in a straight line; it’s gone up in an exponent. The complexity of what we do on a given day doubles every 10 years. Then our population is ageing as well. Between the age of 20 and the age of 80, the use of GP services increases from two-and a-half visits per year at the age of 20 up to 12 to 14 visits by the time they are 80.”
Dr Byrne acknowledged the need for continued medical education and accepted that progress is both necessary and inevitable. He added that the ICGP has “a really important job to do, which is to keep an eye on international best practice and guidance and deliver education”.
He reiterated there was a conflict between the need for GPs to perform to the highest standards and the need to fund that activity.
“Unfortunately, there isn’t a mechanism for the State to reflect in funding the increase in complexity as things change,” Dr Byrne explained.
Guidelines
Clinical guidelines relevant to GPs are issued by various bodies, including the ICGP, the HSE, and the national clinical effectiveness committee (NCEC). The introduction of GP clinical leads – now involved in 13 clinical care programmes, according to sources – has helped enhance educational supports provided by the College, such as GPUs (formerly known as quick reference guides) and webinars on key clinical topics.
Recent GPUs produced by the ICGP include documents on contraception and fertility (2024) and depression (2023).
MI asked the College about the need for additional resourcing to support the implementation of new clinical guidelines. However, a spokesperson said: “The College won’t be making a comment on this at this time.”
Complexity
GPs are not only having to cope with a growing number of clinical guidelines and practice updates.
An ageing population and rising levels of comorbidity mean GPs are increasingly managing more medically complex patients.
The estimated prevalence of dementia, for example, is currently at around 64,000, but is set to double by 2036.
The policy of enabling people with dementia to remain living in the home means that the demand for dementia-based care in the community will only increase further in the future.
According to Dr Tadhg Crowley, Chair of the IMO GP committee, completing the initial stages of dementia assessment and management in line with the latest guidance takes a number of GP visits.
However, Dr Crowley told MI that while the guidance is “fantastic” and best practice, the current pressures on general practice and limited time for consultations make it challenging to implement.
“It puts the GP under pressure. It puts everyone under pressure,” Dr Crowley said.
Dr Crowley noted there were similar issues with other guidance, which often require multiple consultations and can be time-consuming to implement.
He highlighted a disconnect between the development and implementation of guidelines, noting that they are often “topic-oriented rather than job-oriented”.
“We need to be careful,” he said. “… I think we’re entering territory that our own desire to be the best we can be is becoming a millstone around our neck.”
I think we’re entering territory that our own desire to be the best we can be is becoming a millstone around our neck
Medico-legal
Dr Crowley also noted the medico-legal implications, where non-compliance with a guideline could be referenced in a complaint.
“But the guideline was always meant to be a guideline,” he argued.
“The definition of guideline in itself is rather murky. One definition provided described a guideline as ‘a general rule, principle or piece of advice’.”
Dr Rob Hendry, Medical Director and Chief Member Officer at Medical Protection Society (MPS), provided MI with the following statement on the matter.
“When deciding how to manage a patient it can be helpful for GPs to be aware of the relevant guidelines produced by appropriate authorities,” according to Dr Hendry.
“It may be that after considering these guidelines, a GP decides that it is appropriate to follow an alternative path or give other advice to their patient. In such circumstances, it is wise to record the reasons for doing so in the patient’s clinical records, in case the decision is later called into question.”
Dr Crowley said the courts are often “using guidelines as the only way clinical practice should be carried out”.
Implementation
A HSE spokesperson said that guidelines are developed to support clinical practice in various areas of care and provide an easily accessible resource that is evidence-based and peer developed.
“Clinical guidelines are often the result of working groups and/or consultation which routinely involves stakeholder engagement, which can include GPs, GP representative groups, service users, and families,” a spokesperson told MI.
“Guidelines are not limited to the HSE, but are published internationally by various groups and organisations on a regular basis. Some guidelines are complex and do need an implementation plan to support their integration into clinical practice.
“Guidelines apply across the range of healthcare workers. It is true that there is a continuing growth in clinical guidelines, but it is not confined to GPs, and all healthcare workers are similarly challenged both to keep abreast of developments and to implement them in their practice. In general, when the HSE develops guidance which is a significant change from existing practice, it will look at an implementation plan which will identify any required resources.”
Dr Byrne believes that “current best practice standards are racing ahead of the HSE’s ability to keep up with what needs to happen on the ground”.
“Translating a best practice guideline into doing it on the day… can mean extra visits, longer visits, disease monitoring, and the likes of phlebotomy, which isn’t covered on the contract, and increasingly you’re doing phlebotomy three or four times a year for a patient. Back in the 1990s, it was an occasional event.”
GP agreement
Dr Byrne cited the 2019 GP agreement as an example of the current challenges. While he said the agreement, which led to the management of chronic disease in general practice, was a “huge success”, he pointed out that costs have increased since it commenced in 2020.
“We are five years into it now,” Dr Byrne said. “The average basket of consumer goods has gone up 38 per cent in the last six years. Healthcare inflation is at about that level. CPI [consumer price index] inflation is at 22 or 24 per cent over that time period. The costs for GPs have risen by in excess of 22 per cent. The cost of staffing has gone up, PRSI has gone up, entitlement to leave has gone up… we’ve all of this happening and increased guidance and suddenly there’s a mismatch between the need to be progressive and what the State is willing to fund. It’s an inevitable consequence of a system that is largely a fixed payment capitation model.
“What do you do about it? It’s about a periodic review with the State, fair pricing of contracts and there is a mechanism for that in the contract, which is due for review.”
Dr Byrne said there is a need to “temper expectations”.
“To my mind when a guideline is published in Ireland it should be published with a view to offering a guide set that is achievable within current resourcing constraints and it should provide an aspiration for future care….”
“The College is doing a great job; they need to provide up-to-date educational standards. But where the College starts to recommend that visits are mandatory or certain activities are mandatory, it becomes incumbent upon the payer, which is the State, to fund those.”
But where the College starts to recommend that visits are mandatory or certain activities are mandatory, it becomes incumbent upon the payer, which is the State, to fund those
Medical Council
A spokesperson for the Medical Council said that while the Council has no remit over clinical guidelines, it has developed the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (‘the Guide’) to help guide doctors in their day-to-day clinical practice.
“The Guide provides principle-based guidance to doctors on matters related to professional conduct and ethics, with the aim of assisting doctors to safely navigate (within the constraints of the law), situations that arise in professional interactions/the workplace,” a spokesperson explained.
They pointed out the Guide does not address every clinical and non-clinical situation that arises.
“However, understanding and applying these principles will assist doctors to safely navigate situations that arise in professional interactions. We also say that doctors’ practice will be informed by professional, clinical and organisational policies and guidelines.
“When interpreting the guidance outlined in the Guide, it is important to note the term ‘you must’ is used where there is an absolute duty on doctors to comply with the guidance that follows. The term ‘you should’ is used to describe best practice in most circumstances, accepting that it may not always be practical to follow the guidance or that another approach may be appropriate in particular circumstances. In this situation we expect doctors to exercise their judgement.”
The spokesperson said exercising judgement means that doctors may reach different conclusions when faced with the same situation.
“Therefore, if doctors apply this guidance, act in good faith in the interests of patients and respect their will and preferences, they will be in a good position to explain and justify their decisions and actions if a concern was ever raised about their practice.”
The spokesperson said the Council acknowledged the growing pressures placed on GPs.
“Whilst we have no remit over clinical guidelines, we acknowledge that doctors’ practice will be informed by them. And in following clinical guidelines, we expect doctors to adhere to the principles outlined in the Guide.”
Resources
Monaghan-based GP Dr Illona Duffy stated that improvements cannot be made without resources.
“It goes back to what [Prof] Michael Boland used to say about what’s the difference between a consultant and a GP? He would say: ‘A consultant is expected to know a lot about a little and a GP knows a little about a lot.’ Now we’re expected to know a lot about a lot,” Dr Duffy told MI.
“The development of chronic disease management has meant we are managing more and more and we’re having to manage it better and to a higher level and that’s all good. Resources have followed that to some extent. But the disappointment is we are not seeing the rise in the number of GPs.
“The expectation is we do more and do it at a higher level so it’s not just a case of seeing someone with a chronic disease and referring them on to a chronic disease team; we are now expected to handle that and manage that and that has an impact. Funding has helped with that, but it [chronic disease management] can only continue like this if we see a rise in the GP workforce.”
Dr Crowley remarked that given the constraints within general practice, it was his view that guidelines should be interpreted as general advice.
“I’ve always felt general practitioners are exceptionally skilled at their job, which is general practice. We are gatekeepers of the community in a medical sense. Special interests are great. But if it gets to the stage where special interests are taking from the job of the general practitioner, I feel guidelines should be those that are carried out within the realm of general practice and all that it includes in terms of time, energy and resources.”
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