Everyone has a view on GPs. Depending on who you talk to, they are overworked, under-resourced and at risk of burn-out, or they’re overpaid, under-stretched and cruising to a comfortable retirement.
The debate about whether GP practices are at breaking point or mopping up the spoils of a system awash with inefficiencies surfaced again last week with the publication of figures showing what GP practices get paid by the HSE.
In 2017, the HSE paid out €533 million in fees and allowances to GPs. The National Association of General Practitioners and the Irish Medical Organisation (IMO) – which is in negotiations with the Government on a new GP contract – insisted the headline figures are misleading because they take no account of costs such as premises, staff, technology and insurance. Within medical circles, meanwhile, there is talk of GP burn-out, or GPs handing over the keys to their practice and walking away.
We’ve all been a patient at some point. But few of us get to see what goes on outside those 10 minutes of a GP’s working day.
10.15am
It’s one hour and 45 minutes into his day and Dr Darach Brennan has seen five patients, signed 20 repeat prescriptions, followed up on several phone calls and dealt with a handful of house-call requests. “It’s shaping up to be a normal kind of day,” he says.
A good day is one where he is “only” fully booked. A more challenging day means one where he starts out fully booked, and then has to accommodate multiple walk-ins and call-out requests.
He is one of two GPs on duty today at the Johnstown Medical Centre in Waterford, along with a full-time nurse, two receptionists, and a practice manager. It's a medium-sized "mixed" practice, covering both medical card holders and private patients. It was established in the 1990s by Brennan's colleague Dr Paul Walsh who, now an energetic 76, still works in the practice two days a week.
These days it has 4,000 patients – half private, and half medical card holders. By the time the surgery closes this evening 90 patients in total will have been seen, up to 30 for each healthcare professional. They always keep a couple of slots open for emergencies. They’ll never send a sick patient away, Brennan says.
So far today his patients have spanned the full spectrum, from a woman with a new pregnancy, to a man in his 70s. “It’s uncommon for people to come in with just one problem, and that’s it. Most people will come in with two or three issues or more. So it’s not unusual for appointments to take a bit longer,” says Brennan.
His first appointment was a woman in her early 40s who was happy to discover she was pregnant after trying for more than a year. It was a good start to the day, he says.
The appointment after that was a youngish man with a recent diagnosis of a progressive illness. With a patient like that, you have to give him as much time as he needs, and close your mind to the people waiting outside. They talked about his “mood and how he’s coping psychologically with a progressive, chronic disease”.
Then there was a child of five with a “very typical” upper respiratory illness and an eye infection; a patient attending for a methadone prescription; and a man in his 70s who was in for a driver’s licence medical.
10.23am
Miriam has just been in for an antenatal check. She is 34 weeks pregnant. She likes coming here, she says: the doctors are kind, and she never has to wait too long. In the Ukraine she was working in a casino and her husband was a soldier. Now they live in a direct provision centre.
Miriam has been waiting for the papers to allow her to stay in Ireland for three years. But some people in the centre have been waiting “five, six years”. She is worried about space when the baby arrives – all the rooms in the centre are the same size. And she’s worried about money. Between herself, her husband and the baby they will have to get by on €53 a week.
“Would you like to have your own home one day,” I ask.
She misunderstands. “Home? No. I don’t want to go home. This is my home.”
10.37am
Dr Annaliese O’Sullivan is having “a quiet morning”. The rain is keeping people away, she thinks. She is seeing her fifth patient, “a lady who has recently been bereaved and is going through that, as well as dealing with her physical complaints”, when they are interrupted by an urgent phone call.
There is a man at home on the ground, “in terrible pain with his back”. With soap still on her hands, O’Sullivan takes the calls and tries to “make sure he’s safe and that he doesn’t have any red flag issues that would require him to go to the emergency department”.
She is still on that call when a text comes through from the nurse asking her to do a prescription for a patient. The hard part, she says, “is trying to keep all the balls in the air”.
The woman who needs the prescription is one of those who has fallen between the stools of our health system. She has a painful ulcer on her leg, but although she is 80 she doesn’t have a full medical card. This means she is not entitled to get it treated at the public health nurse dressing clinic, and has to come to the nurse.
10.51am
Nurse Maire Hughes is not having a quiet day. She can’t actually remember when she last had one of those. “She’s always running up and down the stairs,” says practice manager Denise O’Keeffe, who comes to bring her a coffee. Otherwise, Hughes says, she’s liable to forget to eat or drink.
“I’m the only nurse here at the moment, so I’m always booked out. Bloods, blood pressure, childhood vaccines, flu vaccines, contraceptive implants, ECGs. I have my booked-in patients, and then I get referrals from the doctors. Someone might walk in and need stitches. Every day is busy, and I just accept it’s busy.”
11.03am
O’Sullivan has a patient who is coming off Valium. She sees a bit of Valium addiction, but she sees a lot more Solpadeine addiction.
“A few will disclose it. They know themselves. They’ll tell me that they’re taking 15 a day, and they’re going from pharmacy to pharmacy to get it.”
11.23am
A young woman has come in to have her Implanon contraceptive implant removed. She agrees to let me watch. O’Sullivan administers an anaesthetic. “Can you feel that, like a little bee sting?” she asks.
“I can’t look,” the patient says, as O’Sullivan makes a small incision in her skin.
“I can’t look either,” O’Sullivan says. Everyone laughs. She extracts what looks like a tiny white cotton tube, slightly shorter and skinnier than a matchstick. There’s hardly any bleeding. “I love a minor procedure,” O’Sullivan says. “It’s a nice break in the day.”
Remember, she tells the patient as she leaves and Hughes begins applying the dressing, “if you swing from the chandeliers tonight, anything could happen”.
11.57am
Billy Lenihan, “81 and four months”, finishes his appointment with Brennan. He is smartly dressed for the occasion in a beautifully cut pin-striped suit.
“I had a good life,” he says, once the introductions are out of the way. His wife died some 12 years ago. They were together nearly 65 years. He digs around in his wallet for a photo to show me. “Wasn’t she a beauty?”
Then he tells me his new partner, Joan, is in Ardkeen hospital. She’s all strapped up after a fall. He went in to see her last night, and ate a bit of dinner with her.
They met on a blind date nine years ago. A friend set them up, and they went to a hotel for dinner, and that was it. She has been there for him when things were difficult. He pulls out another photo, this time of his son. A year and a half ago he took his own life, he says.
Joan, who was an all-Ireland ballroom dancing champion, has taught him how to dance. He likes social dancing, he says. “Not as many things to think about as with ballroom.”
He gets up to show me. “One, two, close,” he says, moving lightly around the room. “You don’t say ‘one, two, three’, because you always have to think ahead, think about how to close.” He moves like a much younger man.
What’s his secret? “Keep moving the body.”
12.45pm
As the practice quietens down for lunch, Denise O’Keeffe, the practice manager, counts up patients seen today. Brennan has seen 14 patients, and three walk-ins. O’Sullivan has seen 13 patients, two of which were longer appointments.
“DNA” is shorthand for patients who “do not attend”. There were six of those this morning, including one for a Mirena coil contraceptive implantation, which would have been a double appointment. In the past month there have been 141 DNAs in four weeks, which averages out two per doctor or nurse per day, O’Keeffe says.
Over lunch, Brennan says the hardest thing about being a GP is that they don’t have enough time.
“You’ve got a patient in front of you, and they often have multiple things going on. You know there are people in the waiting room, repeat prescriptions to do, phone calls to make. The nurse is asking you to have a look at someone. So you’re trying to juggle.
“But if you bring it all back to the basics, the patient sitting in front of you is someone who’s got a physical or psychological or social problem, looking for some help. And usually we can offer help, and usually they leave a little bit enriched, or healthier or happier.”
I ask about the perception that GPs have a tendency to over-refer and over-prescribe. O’Sullivan says she does her best not to have to send someone to an emergency department, “because you need to be in the whole of your health to be able to survive an emergency department. So I will go out of my way to avoid that.”
Brennan agrees. “I sent one person to hospital today, a man with a suspected strangulated hernia. So of the 26 [we] saw between us, we only sent one to hospital,” he says.
“What I find unhelpful about those perceptions [about GPs] is that most of what we do is not measurable. We don’t know how many suicides we might have prevented by breathing exercises or just by listening. We don’t know how many heart attacks or strokes we’ve avoided by checking someone’s blood pressure or getting them to stop smoking. We don’t know how many crisis pregnancies we’ve prevented. That’s the stuff you can’t measure.”
Sometimes the accusations about GPs over-prescribing actually has more to do with lack of access to further services, says Brennan.
“So, for example, if you have chronic hip or knee pain the solution may be to get a new knee or a new hip or timely physiotherapy. Or, for example, if you’ve got mild to moderate anxiety there’s better evidence for CBT [cognitive behavioural therapy] and timely counselling than for SSRIs [antidepressants].” But they can’t always get those things in a timely fashion, so they have to prescribe.
One of the agonising things for GPs is knowing that they are sending their patients into a system that is broken.
“And it is broken. It’s not down to the consultants, the nurses, the physios, the cleaning or the catering staff.
“For example, the waiting list for a routine urology appointment in Waterford is four years. So if I refer a patient for urology, they’ll get a letter back saying they’ll be seen in four years. That’s not a service. Orthopaedics is two or three years. ENT is the same. Eyes are the same.
“If you go to the emergency department, and you’re an elderly lady or man, you may be lying there for two or three days. That’s just unacceptable in any country. And that’s no disrespect to the individuals working in the system, but it’s broken.”
O’Sullivan explains what this means in practical terms. “Today I had a gentleman who, thankfully, has private health cover. He has subtle signs that might point to angina but need further investigation. Because he has been referred through the private health system, he will be seen in a two-week time period. And if there is a problem it’s going to be addressed.
“But if that was a medical card patient then I’d have to ask am I safe to let that patient wait nine to 11 months to get a stress test done? It’s very difficult looking after patients who are worried, and who don’t have immediate access to investigations. I find that really stressful.
“I’ve had situations, and I’m very upset by them, where I’ve made an urgent referral, but their investigation wasn’t done in a timely manner.”
O’Sullivan recently had a patient who had developed metastatic cancer by the time she got her consultant appointment through the public system. “I get very upset by that. The service that patients deserve isn’t there at this time. I find that hard.”
2.15pm
The surgery is about to reopen for the afternoon. Since GP-visit medical cards were made available to under-sixes, the number of visits has gone up.
“I hate under-six bashing. If there’s a child that needs to be seen today, they will be seen today,” says Brennan. “Part of our role, after assessing the child, is to empower the parents with some information about management of a fever, for example, so that they feel confident about treating the child at home.”
Brennan is in the practice three days a week. The other days he is involved in GP training as a programme director for the southeast GP training scheme. He talks about the “need to protect, develop and resource GP training in Ireland, which combines workplace learning with small group teaching, and mentorship … our doctors are wanted all over the world. Many stay in Ireland. Of the trainees that graduated from the southeast last summer, all are now working as GPs in Ireland. So the idea that we’re training them for export just isn’t true.”
3.36pm
An 11-year-old boy and his mum are here for vaccinations for a trip to Nigeria. They're going for Christmas, "for prayer and worship".
She came here as an asylum seeker. She spent six years and 10 months in direct provision, and her son was born here. Now they have their own apartment. Has he ever been to Nigeria? Only once, he says. He’s not excited about their trip though. He doesn’t want to go. “I’m used to here.”
3.48pm
Mary has been in to see Hughes for an injection for osteoporosis. She was nearly a DNA, she admits. She had to get a new battery in her car to come here, but she wouldn’t cancel if she could avoid it. “I’m a real customer, I’m here with Dr Walsh since the beginning.”
After she turned 80 she had three accidents, and each one knocked her back a bit, and it took her a while to recover. Getting older “is nothing to look forward to”, that’s how she would put it. But she’s had a busy life and she is determined not to slow up now.
Mary had four children in five years, and then a miscarriage, and then finally a longed-for fifth baby. She cleaned the church for 47 years, worked in a charity shop for 21 years, and she gave 50 pints of blood in her younger years. She recites these numbers, and grins. “I’ve done my bit.”
As Mary gets older she misses her mother, who died at the age of 33, more. Mary was three at the time. Her father was left to raise the children. “It’s sad. And nobody spoke about it. People used to say we could all have been taken off my father and put into a home, only for I had loads of aunts.”
They were lucky, she knows now.
She is “glad it’s all coming to a head” now, what happened in Ireland during those years. As a child she remembers going down to the Magdalene laundry, to drop in bed linen for washing. “We used to pity the little orphans.” The older generation now – “we feel terrible that we never knew what was really going on”.
Keeping in touch with everyone is her secret to staying well. Coffee with her friend after they collect their pension. “Join something, so that you’ve something to dress yourself up to go to.”
4.22pm
Hughes is checking her cervical smear results. She currently has 105 women waiting for results. “The results are coming back now from the first week in July,” she says.
Her patients are angry about the cervical screening controversy. “And they feel that because it’s women their health isn’t being taken seriously enough. They want to be proactive about their health themselves.”
The system is backlogged since the Government’s offer of a repeat smear to anyone who was concerned. Smears are now taking so long to be processed they have gone out of date. That hasn’t happened to any of the smears sent off from here yet. But it’s good public faith in screening hasn’t been shaken, she thinks.
5.40pm
“General practice is rewarding yes, but it’s changing all the time, and we need to continually adapt to the needs of patients and the community,” Brennan says as his working day starts to wind down.
The business model is not broken, he says, “but it’s creaking”.
“There are an awful lot of GP practices that are on the brink. There are a lot of people who are struggling, who can’t take holidays because they can’t get locums or can’t afford locums.”
The Financial Emergency Measures in the Public Interest (Fempi) Act cut everything back to its bare minimum. By some estimates, GPs suffered funding cuts of 38 per cent under Fempi, while the IMO said last week more than €160 million had been taken out of GP services since the financial crisis.
A deal with GPs on new services and working arrangements is key to the Government’s healthcare reforms, which would see more care in the community and less in hospitals.
The Government announced in the last budget its intention to provide GP-visit cards to an additional 100,000 people. It says it has approved a substantial multi-annual budget for the provision of GP services, and has suggested that improving efficiency in general practice could save up to €100 million.
However, the issues have been described as “challenging” by the Irish Medical Organisation which says general practice is in crisis. It rejected a previous government offer earlier this year. The IMO wants austerity-era cuts reversed and money to be provided for new patient services.
“It’s hard to plan for the future when there’s a lot of uncertainty,” says Brennan. “I know of practices where the GP has just decided to get out, where one doctor has handed the keys to someone else and just gone. In the past there would have been a value attached to a practice. Not so much now.”
With medical card patients, “you’re paid per patient per year, regardless of how many times they attend”. There are different rates per patient, depending on their gender and age. The National Association of General Practitioners has said that GPs get an average of €9 per month for each medical card patient.
“With each block of patients, you get subsidies towards practice nurses, receptionists, managers. So that helps hugely,” says Brennan.
GPs are entitled to payments for additional services, like seeing a patient out of hours through CareDoc, performing sutures or a 24-hour blood pressure monitor.
Private patients are charged €50 for a visit, a rate which hasn’t gone up in 10 years. “Out of every private patient visit, about 50 per cent is gone on overheads like staff costs, building, insurance, light and heat. Then there’s tax on a lot of the rest.”
It’s a challenging time to be in general practice, but “if I was going back into medicine, yes, I’d definitely be a GP again. I’ve no regrets at all.”
Before I leave, he points out the “good things” book, introduced a few years ago. “We write in all the nice things that happen in the practice. It can be a funny story or a card, or a relative dropping a gift in to say thank you.
“For me what makes the job great is the longitudinal relationship with patients. It’s everything from a couple who are trying to conceive, all the way through to end-of-life care, which can be really rewarding too. And all the bits in between
“The hard part is really just trying to deal with demand. And on that note,” he says, heading for the door, “there’s a lady waiting downstairs.”
Some patients’ names have been changed to protect confidentiality
