Answer to the rural general practice crisis?

Converting single-handed practices to two-GP practices in remote areas could help alleviate the rural practice crisis

Dr Jerry Cowley, GP, Rural, Island and Dispensing Doctors of Ireland Group, Mayo

July 5, 2024

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  • The health service is under serious pressure. Our Government struggles to cope with a jaw-dropping escalation of costs. A fairly recent visit to our local ED, where I found a multitude of doctors struggling to cope with the flow of patients, confirmed to me that us rural doctors are being replaced by a growing ED ‘industry’, overwhelmed by an increased volume of work. 

    Ireland has been well served by single-handed family doctors for generations. The continuity of care has been second to none, and its great benefit has been proven by hard research. The IMO and Irish College of GPs have worked tirelessly to ensure proper working conditions and quality standards, not least for those of us based in the more isolated rural areas and our offshore islands.

    Yet everything has changed. Time was when a rural GP could be sure that on retirement, he or she would have a replacement doctor to take over the practice. That seems not so long ago, in a time before the dreaded FEMPI cuts. These cuts were reversed by government to a major degree over time, but not equitably. 

    Rural practice was and still is in many respects the collateral damage from FEMPI. Our problems on the ground continue unabated in rural single- handed practice. The ‘elephant in the room’ is an inability to secure adequate time off due to a lack of locums, further compounding burnout and recruitment and retention difficulties in rural practice.

    The CDM Programme, which can provide a badly-needed resource boost for GPs, cannot achieve the desired effect in many rural practices due to time constraints. In addition, hiring an assistant or appointing a partner can be a financial step too far for many. Even the novel and useful International Medical Graduates (Non-EU GP) Programme is a non-runner for many isolated single-handed practices, due to an inability to generate the funds to pay the extra associate doctor.

    Providing temporary locums is a sticking plaster solution put in place by the HSE to fill rural practices vacancies that no-one else will fill permanently; a ‘fig leaf’ rolled out to cover the void in the rural medical service, where early retirement or resignation is the safety-valve to sanity for those who remain. 

    It is cruel that some caring rural GPs still struggle to find cover to attend a family funeral, go on holidays, or even take sick leave or maternity leave. So many dedicated doctors have already left and more continue to resign. 

    Dr Mireille Sweeney, who resigned recently after 29 years as a GP in Co Donegal, was quoted in the Irish Independent as saying that in the past two years at Ardara Health Centre, the post of GP assistant, GP partner “and my post as principal GP have been offered to 11 doctors, nationally and internationally. [They all showed] genuine interest in the practice but [were] unwilling to accept the demands of a single-handed rural GP practice”.1

    RIDDI – an alternative solution

    There is an alternative solution. The Rural, Island & Dispensing Doctors of Ireland (RIDDI) group has proposed that these single-handed practices struggling with the recruitment and retention of GPs in the more isolated rural areas and on the offshore islands should operate with a second GP appointed to them, fully resourced by the HSE, and become two-doctor practices – the ‘RIDDI 2 for 1’. 

    ‘The RIDDI 2 for 1’ will definitely cost more than just supporting one permanent single-handed rural doctor, but the extra cost of a second doctor can be easily rationalised by the fact that a single HSE temporary GP locum is costing multiples of what it is now costing to support the original GP, as reported recently in the Mayo News.2 If GPs looking for permanent posts can be assured of having their anticipated/ expected time off through having another GP in the practice then they will come to rural areas. Having a second GP would mean no more locum problems and an extra pair of hands to deal with the increased volume endured by GPs in our struggling economic post-FEMPI era. 

    Having worked during my 48-year career as a one-in-one hospital intern as well as one-in-one rural single-handed GP, I can assure you that a well-rested doctor is a safer and happier doctor. 

     RIDDI (Rural Island & Dispensing Doctors of Ireland) was established in 1984 with the aim of sustaining an acceptable level of GP and associated medical services in rural Ireland. Our demand has been for Government to sustain smaller towns and rural areas by providing adequate resources, and so prevent the vicious circle of loss of further services with continuing depopulation. 

    We are glad on behalf of our rural colleagues to have been instrumental over the years in promoting the rural agenda and happy with the support of our rural colleagues, through our representative and professional bodies, to have made some positive progress for better medical services and conditions for rural doctors. These include pension entitlement changes, introducing the concept of co-ops for a proper out-of-hours GP service, and championing the establishment of a dedicated helicopter emergency service (HEMS). 

    RIDDI helped organise the WONCA World Rural Health Conference in June 2022, in equal partnership with the Irish College of GPs and UL School of Medicine. We have been trying to ensure the undertaking of original research on the value of supporting rural practice. We have long felt this is essential in driving forward our agenda for greater supports for rural practice from Government and other funders.

    We contrast the alarming decline in the numbers of rural single-handed practitioners with the corresponding dependence on hospital EDs, and an already overwhelmed out-of-hours service. Time-related research could examine this link as a means of proving the value of our case for the roll-out of novel solutions such as the RIDDI ‘Two-for-One’. 

    Rural Standing Committee

    RIDDI in 2022 called for the setting up of the Irish College of GPs Rural Standing Committee and the appointment of a professor of rural general practice.4  We are glad this has happened already, with the establishment of the committee and with the appointment of Prof Peter Hayes at UL. Motions put forward by RIDDI and accepted at IMO AGMs relate to all GPs in active practice being part of our existing co-ops and single-handed GPs with RPA (rural practice allowance) getting five weeks protected annual leave by locums provided by the HSE. 

    An agreement reached between the IMO and HSE provides funding for a pilot project to support the provision of GP services in isolated and rural areas and while some progress has been achieved, the IMO GP Committee is still pursuing increased supports for those GPs. Recognising the issue of securing locums for annual leave, the IMO also secured a commitment from the HSE for a pilot initiative aimed at supporting GPs who are in receipt of the Rural Practice Support Framework to source locum cover for approved leave periods. 

    While the IMO has not concluded all the details associated with this initiative, engagement is continuing between the IMO and the HSE. It is hoped that the Department of Health Strategic Review on General Practice will lead to further improvements for rural GPs and their patients.

    I was heartened that at the recent Irish College of GPs AGM the following motions from the Mayo Faculty were passed: “College advocates that all GPs have access to out-of-hours services” and that: “College supports the motion that every GP has access to a locum and engages with the IMO on this.”

    RIDDI as a stakeholder in rural Ireland will continue to work in equal partnership with organisations within and outside the medical profession which seek to improve the health of all rural dwellers, especially the most marginalised, including our ethnic travelling community and refugees. We need to be mindful of our duty of care to our planet, and everything we do should be in an environmentally sustainable manner. 

    Above all, we need to be central to the decision-making on the future of rural and semi-rural Irish general practice and have a meaningful representation at any table where decisions are being made which affect us; these need to be rural-proofed. The voices of rural communities must be heard and listened to in a spirit of partnership and equality. “Nothing about us without us.”4

    I look forward to seeing as many GPs as possible at the 37th Rural, Island & Dispensing Doctors Annual Conference in Mulranny, Co Mayo on Friday, October 18.

    © Medmedia Publications/Forum, Journal of the ICGP 2024