There is no doubt that 2013 was a tough year for general practice and the health services in general. Morale is at an all time low, with the withdrawal of resources continually undermining the ability of GPs to deliver services to patients. The arbitrary withdrawal of discretionary medical cards from some of the most vulnerable patients along with the increasing mental health problems in the community is taking its toll on many GPs as well as their patients. 

The HSE Service Plan for 2014 offers no light at the end of the tunnel, outlining plans for at least E619 million in further spending reductions, with a net reduction of 15,000 in the number of medical cards, with around 75,000 set to lose cards.

South Tipperary GP John Gillman is one of many GPs deeply concerned at the way things are going: “Morale is low and many GPs are at breaking point. We have an increasing workload, fewer resources, fewer staff. Many practices have had no choice but to down-size and others have no resources to take on extra staff.” 

Dr Gillman is one of a group of GPs from the South Tipperary faculty that held an emergency meeting recently to discuss how GPs are going to continue to provide a service in this austere climate.

“We have had repeated fee cuts but there is no equality of sharing the burden. We have 2% of the health budget with 98% of consultations, in the UK GPs have 9% of the health budget. We provide a professional service but feel constantly undermined. At some stage the string has to break”, he says.

Another factor is the brain-drain of young graduates: “Many young doctors are leaving the country. In Clonmel hospital alone as many as eight interns have gone to Australia in recent months to work in the same hospital. 

“Is it simply unviable to set up in practice at the moment as there is no financial backing from the banks. At the same time we have an aging cohort of GPs who are approaching retirement, some even taking early retirement. This is a real problem, particularly in the countryside. Many posts remain unfilled, others have very few applicants.”

Maintaining standards of care in an era of austerity is increasingly difficult as GPs witness the fallout and hardship of their patients’ personal situations. 

“Some patients are not going to hospital appointments for fear of incurring costs. Just recently I had a mother re-present with a sick child because she did not have the money to use the prescription from a previous visit. The withdrawal of medical cards for many with chronic illnesses is scandalous – I have one patient with motor neurone disease who had to fight to keep it.

“We are working in a system that appears to be on the point of collapse, with no engagement from the powers that be,” Dr Gillman says.

Withdrawal of medical cards

“The withdrawal of medical cards from the most sick is criminal and amoral”, says ICGP past president and Bray GP Rita Doyle. “It affects the most marginalised in society. I have a nine-year old severely disabled patient whose family has had to fight for a medical card for him when he should have one for life; it should be based on medical need rather than means. His younger brother will automatically be entitled to a medical card under the under-six scheme, but a severely mentally and physically disabled nine-year-old boy may not be – it makes no sense.

“There is no dialogue, just dictatorship from government – it seems that they are cutting back so they can go ahead with the ‘free’ universal healthcare plans. Even with a medical card, the E2.50 prescription charge means that many patients with chronic illnesses still struggle to cope. I see patients in tears on a weekly basis. While the powers that be are busy balancing their books, GPs see the human side”, she says.

Clare-based GP, Genevieve McGuire feels that the demands and pressures on GPs and the economic uncertainty is corrosive: “I am happy to have a job where I am needed and that I can make a difference in people’s lives but there is no doubt that the bottom has fallen out of the private GP market and patients are becoming more demanding.

“The worst thing in my area is the reduction in the hospital service and having to fight tooth and nail to get basic services for patients both there and in the community. We are having to work harder for less”.

Crisis point in general practice

“This is one of the biggest crises in general practice we have seen”, says Damian Sharpe, who has been practising in Clonmel for 14 years. “In July, the South Tipperary Faculty called an emergency meeting in light of all the cuts to discuss how people were feeling. It was agreed that what was needed was a national conference to try to galvanise some ideas about what we should do. 

“On a personal level, as a solo GP with six part-time administration staff, I am finding it very difficult to run my practice. I haven’t passed any cuts onto my staff or patients but I don’t know how long that can continue.” 

Dr Sharpe was in the process of amalgamating with another practice in the town a few years ago but withdrew. “I felt I had to pull out in the end because I thought – why should I take the risk and invest in primary care when the HSE are disinvesting?

“There seems to be a real disconnect between what is needed on the ground and where the Government wants to build primary care centres. For example, here in Clonmel they tried to build a primary care centre but there are two here already. We are feeling increasingly disconnected from policy decisions which are being imposed from a Government that is not in touch with those at the coalface.

“We don’t want to come across as moaning but there are genuine fears about the future. We are physically and mentally tired and incredibly stressed. This will eventually affect patient care. A national crisis requires a national conference, so the spring meeting in Clonmel will be an opportunity for GPs from around the country to get together to see what can be done”, says Dr Sharpe.

Stress and anxiety

“Since the economic crash, the troika bailout and the imposition of three rounds of FEMPI cuts, many GPs are increasingly feeling under more and more pressure. This pressure is not due to any one single fact. The phrase ‘death by a thousand cuts’ springs to mind”, says locum Dublin GP, Peter Sloane, Director of the ICGP Network of Establishing GPs.

“Personally, I am fortunate that although I have seen an increasing number of patients with anxiety and depression as a direct consequence of the economic situation in our country, it has not yet impacted on my own personal mental health. I know some colleagues who are less fortunate and the combined stresses, including the increasing burden of mental health problems in the community, have had a devastating and major impact upon their own personal mental and general health.”

“Certainly within general practice, there has been for some time a progressive decline and worsening of many negative parameters. We are seeing general mental health issues, a sense of hopeless for the future, a sense that general practice may no longer be a viable career, and a sense that the HSE and the Department of Health have no interest in engaging with general practice or any desire to put patients and the so-called Primary Care Strategy at the heart of health policy or planning,” he says.

“Every GP in the country has also witnessed the devastating impact of the recession on our patients, not just in terms of an increase in specific illnesses such as anxiety, depression and alcohol abuse, but in an overall sense of hopelessness that many patients are now experiencing,” Dr Sloane says.

“Much is consequent on unemployment and financial pressures. In this respect, what we see in our consultations simply mirrors the downward spiral of increasing inequity, the squeezed middle, and the massive personal and national debt that Ireland is subject to.” 

• The ICGP spring conference hosted by the South Tipperary Faculty will focus on how GPs are coping in the recession. It will take place in the Clonmel Park Hotel, Tipperary on March 8.