Prognosis negative – Government must act on GP crisis

The ICGP has carried out a ‘health check’ on general practice in Ireland through a major members’ survey, launched at the recent Winter Meeting in Athlone.

Worryingly, when it comes to GPs assessing the state of their working lives and general practice as a whole, the diagnosis is not good. For the prognosis to improve, and for recovery to begin for both GPs and their patients, the ball is definitely in the court of the Government, the survey clearly shows.

Among the many worrying trends highlighted in the survey, by the ICGP’s Claire Collins and Margaret O’Riordan, there are two cornerstone statistics – 95% of the 815 GP respondents believe there is a crisis in general practice, with the threat to its financial viability cited as the most serious manifestation of this; and 90% of GPs feel that communication between the Government and the specialty has failed both doctors and patients.

The detailed findings from the survey, carried out in October, show that these figures are not just another much-repeated PR truism, but are borne out by current general practice realities. For example:

• 77.6% of GPs say their morale has worsened over the past five years, with 74% rating their current stress levels as high or very high
• Only 55.3% of GPs who tried to recruit a sessional doctor or assistant in the past year were able to do so
• Only 44% of GPs who tried to recruit a locum in the past year were able to do so more than half of the times they tried.

The survey found that rating of morale was significantly related to full/part-time status, with part-time GPs less likely to rate their morale as very poor. 

Morale was, perhaps not surprisingly, significantly related to practice location, with higher morale scores for those in village practices.

Worrying too, in terms of doctors’ health and future quality of practice, is the finding that three-quarters of GPs rated their current stress levels as high or very high. Male GPs, full-time GPs and principals were more likely to report high or very high stress levels. Higher stress levels than those recorded five years ago were reported by over three-quarters of respondents.

Obviously, difficulties in finding locum cover and sessional doctors for practices are not helping stress levels. In the previous 12 months, just under 60% of respondents had tried to hire a locum, and of these only 44% did so successfully on more than 50% of attempts. GPs in towns were likely to be more successful in getting a locum than those in villages or cities.

It was found that just under half of those surveyed had attempted to employ a sessional doctor or assistant in the past year and of these, 55.3% were unable to recruit someone. Group practices were more likely to be successful with this recruitment.

Trying to maintain a work-life balance

Amid all this angst, the survey showed that many GPs try to employ strategies to maintain a reasonable work-life balance, including contact with family friends (95.2% of those surveyed); CME meetings/reading (91.6%); physical activity (85.4%); and maintaining boundaries in the doctor-patient relationship (85.4%). Just over two-in-three GPs said they try to maintain time boundaries between their work and personal life.

Tellingly, and probably a factor in the reported rise in stress levels, almost all GPs surveyed (97.4%) said they were concerned about the impact of increased patient demands on their practices. However, only 58.3% try to limit their working hours. Not surprisingly, those GPs who reported high stress levels also reported low morale. 

So it can hardly be of comfort to the Government or to the patients accessing what is still, despite the pressures, a high-quality service; that the average GP is overstressed, overworked and probably pessimistic about the future of the service they are providing.

And there’s more…

In terms of the Government’s attempts to develop services to improve access and quality of care, the survey found that the majority of GPs feel that the under sixes scheme and over 70s free care schemes, introduced this year, will impact on waiting times. 

Not only this, but only one-in-10 of members surveyed believed that free care for the under sixes will result in a healthier population and only 13.6% think it will mean better-monitored patients, with only one-quarter believing it will lead to improved patient satisfaction.

One-third surveyed actually believed the under sixes scheme will lead to reduced continuity of care, always a cornerstone of high-quality general practice provision.

As the majority of GPs had joined the under sixes scheme by the time the survey was carried out, the results would tend to confirm evidence that while GPs signed up for it, they were less than enamoured of it and many felt pressurised to do so.

There was a more positive prediction for the impact of the over 70s free care scheme in terms of population health and better monitoring of patients; however, even here, a high proportion of those surveyed (73%) believed it would lead to longer waiting times, and there was also some negative perception of the over 70s scheme’s effect on patient satisfaction and care continuity.

Opinions on primary care teams

Another key component of Government primary care policy has been the development of primary care teams (PCTs) and centres, ICGP members appear very wary of the benefits of these. While almost two-thirds of GPs support the principle of PCTs, only 13.3% consider they are currently working in a well functioning model of this team. 

Just under one-quarter of GPs indicated a preference for co-location to a PCT in a primary care centre, while a sizeable proportion are currently having nothing to do with these teams – 47.5% are currently not involved in a PCT. Interestingly, the principle of PCTs was, it was found, more likely to be supported by female, part-time and younger GPs, and those in group practice.

In terms of preferred practice location, just under 42% of respondents said they would prefer bi-location with another GP(s) in their own premises. 

In terms of the painfully slow process of moving more care from secondary to primary, almost 87% agreed that this would be positive for patients, but GPs also agreed that this process needs to be resourced.

The majority of GPs (85%), according to the survey, agreed that chronic disease management (CDM) should be moved largely into general practice, as long as appropriate resources, funding and services accompany this. Almost two-thirds agreed that GPs should be supported to become more involved in evidence-based primary prevention.

Crisis in general practice

A huge majority of respondents reported that there is a crisis in general practice, with GPs specifically listing financial viability as a key concern under this heading, followed by availability of GPs.

Asked to identify attributes of general practice it was important to preserve (and which may be under threat due to the crisis highlighted in the findings) GPs identified continuity of care as the most important attribute. This was followed by the doctor-patient relationship; followed by patient-centred care. The doctor-patient relationship was considered significantly more important by GPs in group practices.

Presented with a list of negative impacts of the de-resourcing of general practice in recent years, the consequences most often selected by GPs were doctor availability/employment and effects on quality of service.

Author comments on survey findings

Commenting on the survey findings, the authors have pointed to the fact that virtually all members surveyed feel there is a crisis in general practice.

They note that serious concern has been expressed on the impact of cuts in recent years to general practice resources and income. They cite the impact of the cuts in terms of financial viability, doctor and support staff availability and workforce health, in addition to patient safety and other factors including reduced services. The authors describe as a ‘striking finding’ the fact that 90% of GPs felt that communication between the Government and the specialty in recent times has failed both doctors and patients.

Other worrying findings noted by the authors include the concerns about the under sixes scheme, stress and low morale, and the perceived poor functioning of and lack of GP enthusiasm for PCTs. This, the authors say, clearly shows more work needs to be done to engage GPs better with these teams.

The authors felt the more encouraging findings of the survey included the identification of the core elements of Irish general practice, including continuity of care, the doctor-patient relationship, and patient-centred care, which, they stress, are important attributes to preserve.

They also noted the positive support for moving CDM to and developing preventive medicine in primary care, with the proviso that resources needed to follow such initiatives.

The authors stress that research shows that factors such as work overload, lack of control over work demands and insufficient reward for work volume and complexity are all risks for professional burnout.

The survey, the College feels, points to the need to promote job satisfaction and morale among GPs.

In summary, while GPs are clearly supportive of new developments and an expansion in the role of general practice, “this support can only be translated into reality if adequate supports and resources are put into general practice”, the survey concludes. With an increasing number of GPs becoming disillusioned and stressed, and many opting for emigration, the findings indicate that these measures need to arrive sooner rather than later.

Identifying GP manpower as a key issue here, the authors say: “The current GP workforce cannot continue to function unless this situation is addressed as a priority by Government. New organisational arrangements, advancing the planned reversal of financial cuts, and implementing workforce improvement strategies are critical to this recovery.”