"The problems of the dispensing doctor of those days were truly appalling. He had to trudge long miles on foot, and ride through bogs and up watercourses to reach his patients. His pay was hopelessly inadequate and he had no regular pension so that he hung on long after he was fit for work. Many died of overwork and quite a few from drink. It was a hopeless and thankless job . . ."
The above is a description of the lot of the rural general practitioner, or dispensary doctor, of the late 19th century from Dr Robert Collis's book The State of Medicine in Ireland. While clearly no longer "trudging on foot" or "riding through bogs" to reach his patients, the modern-day rural GP's life remains a unique and demanding one.
One of the principal demands of the job is the need to be "on call" for extended periods. Unlike their city counterparts, who pool their resources or employ deputising agencies to spread the workload of weekends and nights on call, some rural practitioners are still on call 168 hours a week. This is known in the trade as the dreaded "one-in-one", when you are on duty all day and all night seven days a week.
Unsurprisingly, such a professional life can be a difficult one. Research shows that it is the "out-of-hours" care that GPs find most stressful. A study by Prof Andrew Murphy and others in the Department of General Practice and Health Promotion at the National University of Ireland, Galway, looked at the number of out-of-hours consultations carried out by GPs in the North Western, Western and Mid Western health boards. During 1998, 412 GPs saw a total of 102,286 patients outside normal surgery hours. Significantly, rural practitioners saw 295 patients per 1,000 population compared to an out-of-hours consultation rate of 220 per 1,000 for their urban colleagues.
Dr Nuala Cuddy, also of the Department of General Practice, NUI, Galway, carried out a qualitative study into rural general practitioners' experience of out of hours care. Ten rural GPs on the western seaboard participated in the study. Of these, six had single-handed general practices. The distances between the GPs' practices and their local hospitals ranged from 15 to 50 miles. Published last April in the British Journal of General Practice, the study contains some remarkable insights into the lives of rural doctors and their families.
The themes pursued by the researchers included night calls, dealing with problem patients, the demands of the job on family and social life, 24-hour responsibility for patients' lives and time pressures.
Sleep interruptions were viewed by all GPs as particularly stressful. "I don't sleep any more when I'm called" . . . "You get to a stage with night calls that you are not able to sleep" . . . "On my nights off, very often I take a sleeping tablet" . . . "I am not a good sleeper, my job has made me that way."
Some of those interviewed greatly regretted being unable to give sufficient time to their families and felt they were missing out on their children growing up. "I am afraid I am grossly negligent of my family, I am so busy." Spouses provided significant emotional and practical support for the GPs, the study found. Being on call not only restricted doctors' own lives but also those of their spouses, who found it difficult to pursue any social activity outside the home in the evenings. "My husband couldn't mind the children if I wanted to go to a night class when he is on call" is a typical comment.
Even when the rural practitioner is on a rare break from medical call, spouses still have to deal with awkward situations at the door or on the phone, as this startling quote from a GP's spouse shows: "If he is here and off-duty . . . he is hiding in the sitting-room . . . his car is around the back. I am sort of doing guard at the front door . . . That is what I call doing the GP wife act."
According to the GPs, locum doctors are not interested in coming to rural areas to give them much-needed time off because of the isolation and the larger catchment areas. The smaller volume of private fees compared with urban practices is another factor contributing to the difficulty of finding locums.
Catherine Duffy, development officer with the Primary Care Department of the Western Health Board (WHB), says: "Finding locums was not a serious problem until this summer." Already she has been unable to secure locum GPs for two single-handed doctors who require urgent, long-term cover.
The WHB plans to introduce a new form of 24-hour medical care from October 1st. A GP co-operative will be established to cover medical practices in Co Galway, using a model already successfully piloted in the South Eastern and North Eastern health boards. A single call centre, staffed by receptionists, nurses and GPs, will deal with all out-of-hours calls and offer patients appropriate responses. These will include the possibility of a home visit from a mobile doctor or attendance at one of a number of regional medical centres. Such a system will undoubtedly make most rural practices more attractive to doctors. However, because of the unique geography of the western seaboard, this model will not work for all GPs and their patients.
╔amon ╙ Cu∅v, Minister of State for Rural Development and TD for Galway West, acknowledges this. "West Mayo and Connemara have no town with a population greater than 4,000 people," he says, referring to the difficulty this poses in finding a suitable location for an out-of-hours medical "hub".
"I would like to see a flexible framework within which different arrangements are worked out. There is a need to go beyond a single model of out-of-hours medical care and explore other options," he says.
Drawing on his experience in securing the future of island populations off the west coast, he says. "It is the maintenance of key services such as education and health, more so than jobs, which will help to reverse rural depopulation."
Clearly, buttressing still-viable medical practices is essential to rural development. Duffy outlines some initiatives undertaken by the WHB to help single-handed GPs. "We offer up to £9,600 per annum as an onerous rota grant for GPs to employ sessional doctors," she says.
Last year, the WHB contracted a newly established locum agency, Locumotion, to provide holiday cover for the region's GPs. In addition, the GP unit of the board has offered grants of £100,000 payable over four years to the five GPs in the region who are on continuous medical duty. It is a short-term measure to enable doctors recruit assistant GPs. Ominously, with an end-of-July deadline, so far there has been no firm interest in these grants.
Two single-handed GPs, Dr Joe Curran and Dr Patricia Henaghan (see panels), believe there would be immense difficulty filling their positions should they leave or be forced to retire prematurely. With patient list sizes falling by up to 30 per cent and an ageing population, the future looks bleak for some rural practices. It is time for innovative and imaginative solutions if one of the essential services for rural communities is to survive.