In the words of the poet Lorcan Brennan:
“It is necessary to stop. To look about.
See the distance, the height attained, the
Journey in the bag. Rest easily assured
Life has its meaning”.¹

Little did we know when the joint ICGP/IMO Chronic Disease Management Programme regional meetings started in mid-January 2020, what lay ahead of us. The meeting I attended in Kilkenny on January 23 in a hotel room overflowing with colleagues now seems somewhat like a foreign country. General practice had travelled a long journey since the FEMPI cutbacks of 2008-13 and we gathered at those meetings to hear how a way might be forged ahead and how we could plan towards the increased workload that would be coming our way.
A month later, many of us were combing local DIY stores to secure visors, goggles, and any other available PPE for an evolving pandemic. Approaching the end of 2021, we are in the fourth wave of this pandemic, with Covid-19 now being endemic. Changes have come about in the delivery of general practice services that probably were not on most of our minds at the time of those regional meetings. Telemedicine is now an embedded part of our work and, where clinically appropriate, will serve our patients well going forward. Some things we won’t miss and we look forward to when we can live without them again, such as the still almost ever-present mask.
I recently came across a phrase "The pandemic did not change us: it revealed us”. I think that with the passage of time, we will look back and see that the essence and strengths of general practice have been visible to us in this time, despite all the challenges. There is much pure gold in Irish general practice that has stood the test of the past two years.
However, we have also an increasing awareness of weaknesses in our current work situation that already do, or potentially can, undermine the services we provide. We are all too familiar with the mismatch between our early 1970s-originating contract and 21st century workforce needs.
The IMO, in its 2022 pre-Budget submission, quoting from its ‘Report of the Survey on Doctor Mental Health and Well-being said’: “59% of GPs stated that they were unable to take time off due to difficulties in sourcing locum cover while 66% said they been unable to take sick leave.”²
This is no surprise to many of us and there seems to be an increasing awareness of this in the media. This reality is certainly an example of where the facts of the situation will disguise the underlying personal impact for any people thus affected. It may well also be applied to other situations such as the struggle a number of our younger female colleagues will experience in trying to get maternity leave cover; or personal situations such as bereavement or family crisis.
Excessive work demands will lead to burnout (indeed, in the same report, the IMO reported that 62% of GPs show a high risk of burnout). Anyone affected may experience physical or mental symptoms including fatigue, decreased concentration, anxiety, depression. Burnout has also been shown to be a risk factor for cardiac disease.³ Maladaptive mechanisms may also develop/worsen including misuse of alcohol, drugs, potentially gambling, etc.

E-prescribing

Immense gains were made in 2020 with GP prescriptions now transferring electronically to the pharmacy. It is vital that e-prescribing is also introduced in our hospitals and secondary care facilities. The alternative at present is that if the public patient does not present their hospital prescription to the pharmacy in the requisite interval, it then has to be transcribed/ re-prescribed by the GP. This is not sustainable in the long-term given the ongoing increasing workload, particularly for age-related multimorbidity and polypharmacy.
Further delay in streamlining this aspect of medical care, and in introducing an online prescribed and dispensed medication record that is accessible to all relevant healthcare professionals (doctors, dentists, and pharmacists) can only result in increased risk of medication error.
The Medical Council held a public consultation this summer in preparation for its publication of the 9th Guide to Professional Conduct & Ethics for Registered Medical Practitioners. It is essential that it reiterates the primacy of prescribing for any individual doctor and that if a medication is being commenced, that it be prescribed with requisite monitoring of bloods, ECGs etc. being arranged by the prescriber. The present alternative of a not infrequent unilateral recommendation/suggestion being made to the GP (despite the patient continuing to attend the specialty) no longer serves cohesive delivery of medical care well in many situations.
The children’s toy ‘Buckaroo’ in some ways captures the metaphor of GP overload at this point. (The game involves players taking turns placing various items onto the mule’s back without causing the mule to buck up).
Dr Clare Gerada wrote in the British Journal of General Practice editorial in July about the importance of not continuing “to treat primary care as a ‘sink hole’ absorbing unlimited work”, and that “we need to stop the inordinate expansion of GPs’ roles”.⁴

Ongoing workforce planning

Ongoing medical workforce planning for the next decade and beyond is essential. Achievements with chronic disease management in the last two years have laid foundations for the future. However, some aspects of the present general practice landscape, in particular with regard to the difficulty sourcing locum cover, brings to mind the Dutch legend of Hans Brinker plugging the hole in the dyke. Normally, we speak of patients’ unmet needs; however, If we don’t proactively identify and address GPs’ ‘unmet needs’, there will simply be more holes to plug.
Some of the steps needed to address these needs lie in the legislative/political sphere, eg. setting up a state locum pool, similar to the provisions open to schools if there is a teacher absence. Should there be a more appropriate alternative open to us, then a state-sourced locum pool would of course prove unnecessary.
Given expected GP retirements in the coming years, with the potential for accelerated resignations due to work pressures, this is not a time for protracted delays in resolving the locum scarcity. Were the State to offer employment to all GP graduates as locums it could be considered that this may ultimately halt the attrition of qualified GPs who, with time, may then wish to move to the benefits of being in a practice long-term. We no longer have the luxury of not being solutions-focused.

Reaching out

As well as reaching outwards beyond our profession, it remains essential to reach out to each other. Lift the phone, send the text, and even in the one building – drop in. And for you the reader, or I, or anyone who may be finding it tough going at the moment, let us remember Brendan Kennelly’s words: “Begin to the loneliness that cannot end since it perhaps is what makes us begin.”⁵ When asked what he meant by this line in 1997, Kennelly wrote of the loneliness as “both a casual kind of pain and a real stimulant. A natural condition, a pointer out of the self, an invitation to act through language.”⁶

Similarly, if one is having a difficult time, one is never alone and if it feels as if you are not being reached out to, then you reach out… there will always be a colleague and friend who wants to hear from you – and just be there.  

References

1. ‘Retrospect’ by Lorcan Brennan, Little Hermit & Other Poems published privately 1990’s
2. IMO Pre-Budget Submission 2022 https://www.imo.ie/news-media/news-press-releases/2021/irish-medical-organisatio/IMO-Pre-Budget-Submission-2022-Final.pdf
3. Garg PK, Claxton JS, Soliman EZ, et al. Associations of anger, vital exhaustion, anti-depressant use, and poor social ties with incident atrial fibrillation: The Atherosclerosis Risk in Communities Study. Eur J Prev Cardiol. 2020. doi:10.1177/2047487319897163.   
4. General practice in crisis: stop skinning the cat. Dr Clare Gerada. British Journal of General Practice 2021; 71 (708): 292-293.  https://bjgp.org/content/71/708/292
5. ‘Begin’ by Brendan Kennelly, accessible at https://inclusivelivingnetwork.ie/brendan-kenneally-peom-begin/
6. Personal letter received from Brendan Kennelly Autumn 1997