Chronic shortage of GPs in ireland soon to become critical

On News at One on 14 January, HSE chief Brendan Drumm came out fighting on the news of imminent strike action in the health sector. This combined with a cut of over €1 billion for the HSE and unions saying they won’t cooperate with ‘reform’ means there are particularly challenging times ahead for the HSE. Crucial but separate to the HSE are local GPs. Yet we already have a shortage of GPs and are facing a real crisis in GP care.Currently there are 2,500 GPs in Ireland. We have many fewer GPs per population than the European average.

•            In Europe there is one GP for every 1200 people.

•            In Ireland there is 1 GP for every 1600 people

•            in some areas such as the North Inner City in Dublin, there is 1 GP for every 2,500 people.

•            So there’s a real shortage now and it is even grimmer when we look to the future.

There are two key themes to the changing face of GPs in Ireland in 2010

•            there are increasing numbers of women in the professions. In 2008 40% of GPs are women.

•            The ageing of GPs in Ireland. In 2006 the average age of GPs was 51, most of whom are men, which means that many of these will retire in next ten years.

•            We also know that women are less likely to work full time and are more likely to wish to retire early.

There are also very clear geographic differences.

Research carried out by Steve Thomas in Trinity and Richard Layte in the ESRI shows that

•            Commuter Dublin counties fare worst – Meath, Kildare, Laois and Monaghan.

•            Cork, Waterford, Tipp South and Galway doing best in terms of numbers.

There is a clear east west/south divide. And when projections are made this is exacerbated. Dublin’s GP coverage rate is about average but we know that some urban deprived areas and some rural areas are particularly badly served.

So why can’t the HSE decide where GPs go so that the distribution is more even?

The crazy way the health system is organised in Ireland means that GPs operate as self employed businesses so the HSE has little or no control over where they go.

That said about 60% of GPs’ income comes from their medical card patients, so most GPs will go to a practice where they will inherit a GMS list. The HSE could be more proactive using incentives like GMS lists to attract GPs to certain areas, particularly those less well catered for.

We don’t we have enough GPs because we do not train enough of them.

At the moment we train 121 a year, about to go up to 132 in the next academic year but it has been recommended that it be 150  per year.

However if you look at ESRI/Trinity population projections combined with the HSE policy to shift care from hospital to the community, in order to meet the need of an ageing, growing population, with increasing amounts of chronic diseases, according to Thomas and Layte we should be training 250 a year.

There are other ways of coping with the shortage in the short term as training takes time and is very expensive.

Some medical graduates can be fast tracked as GPs which is beginning to happen now.

Also ‘substitution’ is an option, ie using other health professionals to do some of their work eg Pharmacists and nurses (known internationally as noctors and durses). Again this is beginning to happen in the hospital setting but could be applied to the community and primary care.

Delaying retirement or attracting those qualified who has left practice to come back in to practice are other ways of beefing up the work force. The HSE could use incentives to attract GPs eg assisting with start up costs, linking to good diagnostics and utilising the powerful tool of GMS list allocation.

Given that costs are generally going down, why are GPs fees not going down?

According to the ICGP today, they said the fees have not gone down. However I have heard anecdotal evidence of cost reductions. Also ICGP keen to point out that GPs say they give discounts all the time and that there is already competition within the fee structure as doctors choose patients. Also GP fees (remember this is 60% of their income) for medical card holders have been cut by 8% since last July (and by further 6% now) so GPs say their income is being hit significantly which may explain why there has not been a widespread cut in fees for patients who have to pay out of pocket each time they see a GP.

There are no official figures on average pay for GPs. Each year the HSE publishes money paid to GP practices for GMS lists but these are not a fair reflection of GP salaries because they cover GP practice costs eg building, staffing, diagnostic equipment etc. However the research cited above says that Irish GPs are paid much more than their European counterparts – double that of Italian GPs and even more than that of French GPs.