FOR the past two decades, I have spent large chunks of time on the Iveragh Peninsula, travelling the roads, by- ways and mountain paths in every type of weather and circumstance.
There is probably nowhere in the world that can match it in terms of inestimable beauty and community bonds.
And yet, the area is devoid of family doctors. Once served by six GPs across the two major townlands of Caherciveen and Waterville, it now has just three - all male. One is a locum on a temporary contract and another is due to retire soon. The population has surged with the arrival of almost 1,000 Ukrainian refugees.
Why is it so difficult to attract GPs to a rural idyll with strong cohesive communities that is well-served by a plethora of cafes, restaurants, bars and other amenities?
Dr Brian O’ Donovan, GP in Cahersiveen for 23 years, is due to retire but finds it difficult as he lives in the area and his neighbours are his patients.
“In a GP sense, we just need feet on the ground. The work is perfectly fine, but we need the numbers,” he said.
Dr O’Donovan has a number of suggestions to make the position more attractive including advertising for a part-time GP; making a locum post less onerous by removing the requirement to do out of hours work; and to further progress the initiative to invite non-EU GPs to train and work in rural areas.
Another suggestion is the possibility of merging practices in Caherciveen and Waterville if permanent GPs are found - this would allow doctors to support each other, cover for holidays and be more collegial.
Tascfhórsa Uíbh Ráthaigh, a local taskforce charged with increasing the local population suggests offering HSE-funded supports to GPs for the opening years of a contract - making setting-up in a new area less onerous, including rent and salaries for employees.
In a 2022 Irish College of General Practioners (ICGP) discussion paper, the authors stated that the primary care workforce needs to increase by over a third (37%) to meet demand.
Factors contributing to the GP workforce deficit include a growing population, people living longer with more complex and incremental needs and an ageing GP workforce.
Factors contributing to general practice workload issues include the Sláintecare policy to expand free GP care for all and a renewed focus on retaining patients within the community and out of hospital.
The paper identified key options to resolve the GP workforce and workload crises including the expansion of multidisciplinary teams and practice nurses, providing suitable GP premises and investment in data informatics.
Potential solutions directed at rural GP practices include the support of non-EU GPs to become valued members of the workforces, increasing the capacity for remote consulting, increased exposure to general practice and rural general practice in medical schools and the introduction of a career pipeline for rural general practice.
How do these options translate into increasing rural GP numbers on the ground?
The next generation of GPs will do things differently.
Single-handed GPs, particularly in rural and remote parts of Ireland, are finding it increasingly difficult to find a successor or locum cover. The 2021 ICGP membership survey showed a one third of GPs were unable to take annual leave due to a lack of cover.
GPs are working longer days, placing extra workload pressures on staff and themselves. These factors fuel GP burn-out and impair GP recruitment, exacerbating our workforce deficit. Most newly-qualified GPs wish to work in group practices, close to cities and in practices that combine clinical care, teaching research and specialist opportunities. At present, 15% of the GP workforce work in rural practice.
An ICGP Recent Graduate survey in 2021 reported that fewer than 4% of recent graduates (those who qualified in the last 5 years) want to do so in the future.
Non-EU Rural GP programme
The ICGP and HSE recognise the Non-EU Rural GP programme as an important component of the multifaceted ICGP response to the GP workforce crisis in rural Ireland as the workload shortage has profound implications for patient care and patient safety. The initiative enables non-EU GPs to work in routine daytime, rural general practice for two years with some GP out of hours work. The ICGP and ‘host’ GP provide substantial ongoing educational supports and clinical supervision.
Remote consulting
Pre-Covid, almost two-thirds of GP practices had telemedicine facilities and about 10% of GP consultations were telemedicine consultations. The pandemic changed all that, with GPs embracing video consultation as an important component of healthcare. While recognising the ‘gold standard’ of a physical appointment, at a time of crisis in the rural GP workforce, remote consultation can play a significant role in giving access to professional healthcare effectively in many situations.
Special Supports for Rural GPs
A third of our population is rural and cared for mainly by rural general practices. Many of these are single-handed. The ICGP highlights the vital aspect of this continuity of care that is associated with reduced need for out-of- hours services and acute hospital admissions, ED attendance and decreased mortality.
But the rural GP infrastructure is especially fragile. The ICGP suggests general practice training must include a specific rural focus and investment in rural healthcare should be ‘co-created with rural communities’. Amalgamating rural practices is not necessarily a desirable or viable solution given the distances involved. However, resources can be shared such as nursing, admin, GP locum, sessional GPs and practice management staff.
GPs in rural Scotland and Australia have locums provided by the health authority, guaranteeing their annual and maternity leave.
Rural general practice is in crisis across Ireland, highlighted by the acute dearth of GPs in one of Ireland’s most idyllic locations on the Iveragh peninsula. This has been aggravated by changes in the GP workforce and workload but also by a new generation of GPs who want to work in new and innovative ways. This includes a focus on a healthy work-life balance, a certainty around holiday, sick and maternity leave, telemedicine supports to facilitate workload and comprehensive incentives to support initial set- up costs. Additional potential supports include amalgamating resources between practices that could make all the difference in providing a tenable work-life balance and improving collegiality.
The old ways of doing things are not going to solve the problems. Huge pressures on rural GPs must be alleviated by comprehensive resourcing to retain existing doctors, and attract new family doctors. Rural general practice can be hugely rewarding but unfortunately, has not moved with the times and has reached breaking point.
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