A day in the life of a GP

GPs are be­ing asked to do more for less, and the cracks are be­gin­ning to show

The Irish Times - Tuesday - Health - - Front Page - June Shan­non

I’m not just a GP. I’m your spe­cial­ist in life.

This is the tag line from a pow­er­ful pub­lic aware­ness campaign by the Royal Aus­tralian Col­lege of Gen­eral Prac­ti­tion­ers. It was de­signed to help GPs raise aware­ness of the value of gen­eral prac­tice and the im­por­tance of GP train­ing and ed­u­ca­tion.

The GP is not just a GP. He or she is also a coun­sel­lor, an ad­vo­cate and life-long con­fi­dante who cares for pa­tients dur­ing some of the most vul­ner­a­ble times of their lives.

GPs are in it for the long haul, with many car­ing for pa­tients from the cra­dle to the grave.

In Fe­bru­ary 2015, former GP then min­is­ter for health and now Taoiseach, Leo Varad­kar, signed a mem­o­ran­dum of un­der­stand­ing with the Ir­ish Med­i­cal Or­gan­i­sa­tion sig­nalling the be­gin­ning of ne­go­ti­a­tions for a new GP con­tract.

Two years on and the ne­go­ti­a­tions are on­go­ing. A new con­tract can­not come soon enough for GPs in Ire­land, many of whom are strug­gling to care for pa­tients un­der the terms of an out­dated con­tract that was first ne­go­ti­ated al­most half a cen­tury ago.

Gen­eral prac­ti­tion­ers are for the most part self-em­ployed pro­fes­sion­als who care for both pub­lic and pri­vate pa­tients in the same surgery. Pri­vate pa­tients pay a fee and pub­lic pa­tients (those with a med­i­cal or doc­tor visit card) are cared for un­der the terms of the Gen­eral Med­i­cal Ser­vices (GMS) con­tract be­tween GPs and the govern­ment.

When the GMS con­tract was in­tro­duced in 1972, GPs were paid on an “item of ser­vice” ba­sis. This was sub­se­quently changed in the 1980s to a cap­i­ta­tion sys­tem. A GMS pen­sion was also in­tro­duced.

Apart from a num­ber of add-ons, the GMS con­tract has re­mained largely sim­i­lar since. The same can­not be said for gen­eral prac­tice, which has been com­pletely trans­formed over the past 45 years.

The GMS con­tract is es­sen­tially an acute care con­tact de­signed to re­flect gen­eral prac­tice 40 years ago when pa­tients pre­sented with an acute ill­ness, in­jury or in­fec­tion. It in no way re­flects gen­eral prac­tice in 2017 when GPs are car­ing for in­creas­ing num­bers of pa­tients on mul­ti­ple med­i­ca­tions for a num­ber of chronic con­di­tions.

The GMS con­tract was drawn up be­fore the era of pre­ven­ta­tive care and long be­fore suc­ces­sive govern­ment poli­cies pro­moted trans­fer­ring care from hos­pi­tals to the more cost-ef­fec­tive set­ting of pri­mary care. While this trans­fer of care is wel­comed by GPs, who are more than qual­i­fied to pro­vide it, it has not as yet been fol­lowed by the ap­pro­pri­ate re­sources.

The Fi­nan­cial Emer­gency Mea­sures in the Pub­lic In­ter­est (Fempi) leg­is­la­tion re­sulted in a 38 per cent cut to GP fees across the board. These cuts have had a sig­nif­i­cant neg­a­tive im­pact on the spe­cial­ity.

There is a short­age of GPs and a large num­ber are due to retire shortly.

Tellingly, for the first time a num­ber of GP train­ing places re­mained un­filled in the 2017 in­take. The short­age also means it is get­ting in­creas­ingly dif­fi­cult and al­most im­pos­si­ble in some ar­eas of the coun­try for GPs to find locums for hol­i­day cover.

GPs are leav­ing to work in Canada, Aus­tralia or the Mid­dle East where the fi­nan­cial re­wards are greater.

Un­til re­cently pa­tients could get a same-day ap­point­ment with a named GP, but in­creas­ing pres­sures mean this is now un­der threat, with pa­tients in some parts of the coun­try re­port­edly wait­ing a num­ber of days.

GPs are be­ing asked to do more for less and the cracks are be­gin­ning to show.

The Ir­ish Times asked a num­ber of GPs around the coun­try to record one full day in their prac­tice ear­lier this month.

Mary Favier

“The petrol tank is empty. It is start­ing to splut­ter and come to a halt”

Dr Mary Favier has been work­ing as a GP in Cork for 27 years.

Dr Favier started work at 8.30am and used the time be­fore her first ap­point­ment at 9.15am to catch up on pa­per­work. This in­cluded fill­ing out forms for a carer’s al­lowance and med­i­cal card ap­pli­ca­tions. The large amount of pa­per­work GPs are re­quired to do was some­thing all the doc­tors in­ter­viewed for this piece re­ported as in­creas­ingly time con­sum­ing. She also re­viewed blood re­sults, re­ceived phones call from a phar­macy and a nurs­ing home, dealt with an emer­gency where an in­jured pa­tient needed to be re­ferred to the ur­gent care cen­tre, filled out pre­scrip­tions and re­viewed a medico-le­gal re­port. She then started her morn­ing surgery. Her first case was an an­te­na­tal check up; she then saw a pa­tient com­plain­ing of sweats and weight loss and ar­ranged an out­pa­tient re­fer­ral. Her next pa­tients in­cluded cases of vari­cose veins, sci­at­ica, rash, hay fever, chicken pox, and a child with tummy pain. She also saw a pa­tient with di­a­betes who needed to be fit­ted with a blood pres­sure mon­i­tor, and a num­ber of pa­tients who were suf­fer­ing with men­tal health prob­lems such as de­pres­sion, anx­i­ety and se­vere stress.

At 1pm, Dr Favier spent two hours do­ing more pa­per­work, in­clud­ing hospi­tal re­fer­rals, pre­scrip­tions and a hous­ing sup­port let­ter for one of her pa­tients at risk of be­com­ing home­less.

At 2.30pm, Dr Favier had a sand­wich at her desk while she dealt with emails and re­viewed more blood re­sults.

At 3pm, the af­ter­noon surgery in­cluded cases of con­junc­tivi­tis, a check-up for a new mother and her six-week-old baby, an el­derly di­a­betic who had re­cently suf­fered falls and also needed be­reave­ment sup­port, a den­tal ab­scess, women’s health, a pa­tient who had suf­fered pe­ri­ods of un­con­scious­ness, an­other who was suf­fer­ing with anx­i­ety and de­pres­sion; a pa­tient with chest pains, an­other with fer­til­ity is­sues and an el­derly pa­tient who re­quired a re­fer­ral to the lo­cal falls clinic.

At the end of the day’s surgery, Dr Favier re­turned phone calls to pa­tients, dic­tated three let­ters and filled out more pre­scrip­tions. She fin­ished work at 6.35pm and ad­mit­ted that she had not man­aged to clear all the day’s pa­per­work.

For Dr Favier this was “a pretty stan­dard day”.

“I have no is­sue work­ing hard, my prob­lem is once I am done and go­ing home at 7pm I can’t do any­thing else. My head is just blown . . . it spills over for an­other two or three hours in the evening when your head isn’t right yet be­cause it is too in­tense. It is not re­al­is­tic to keep go­ing at that pace but un­for­tu­nately that is what it is these days,” Dr Favier says.

The re­spon­si­bil­ity of hav­ing to care for more and more pa­tients with com­plex chronic con­di­tions, in­creas­ing pa­tient ex­pec­ta­tions, and re­duced fees means GPs like Dr Favier are con­stantly be­ing asked to do more for less.

While she loves gen­eral prac­tice and

Un­til re­cently pa­tients could get a same-day ap­point­ment with a named GP. In­creas­ing pres­sures means this is un­der threat

couldn’t imag­ine do­ing any­thing else, she would not en­cour­age a young doc­tor to en­ter the pro­fes­sion.

“There is no plan: they [the Govern­ment] have moved for free GP care for all with ab­so­lutely no sense of how that is go­ing to be achieved.

“Gen­eral prac­tice has trans­formed in 30 years in terms of the com­plex­ity of what we do and I just don’t think that is ei­ther recog­nised or ac­knowl­edged.

“It is un­sus­tain­able to con­tin­u­ally ex­pand our role and what is ex­pected of you un­der the cur­rent for­mat. It needs to be struc­tured and gen­eral prac­tice needs lots more money.

“The GPs don’t need lots more money but gen­eral prac­tice does. We need proper fund­ing, we need ad­vanced nurse prac­ti­tion­ers and we need proper pro­to­cols.”

Dr Favier de­scribes the pres­sures of a busy prac­tice as “a con­stant fog” and like many of her col­leagues she wor­ries about “drop­ping the ball”.

“All GPs talk about it all the time, that they have a slight back­ground anx­i­ety that they are just run­ning so fast that they are bound to neglect some­thing.

“The petrol tank is empty. It is start­ing to splut­ter and come to a halt and in some places it is off the road. If some­thing is not done you won’t be able to put it back on the road.”

Sinéad Cronin

“Pa­tients’ ex­pec­ta­tions are higher than they have ever been. We live in a so­ci­ety where ev­ery­thing is in­stant”

Dr Sinéad Cronin is a young doc­tor prac­tis­ing in Dublin. She qual­i­fied as a GP in 2016. A year into the job, Dr Cronin says it was the va­ri­ety of gen­eral prac­tice that at­tracted her to the pro­fes­sion.

Dr Cronin started the day with a walk-in clinic. Run­ning from 8.45am to 11am, the clinic is de­signed as a quick, one prob­lem per ap­point­ment, ser­vice.

Dur­ing the clinic, Dr Cronin treated a pa­tient with tin­ni­tus, di­ag­nosed a new case of type 1 di­a­betes, pro­vided a med­i­cal check-up for a mort­gage ap­pli­ca­tion, re­viewed a pa­tient with chest pain, signed in­di­vid­u­als as fit to re­turn to work and ad­vised two pa­tients about fam­ily plan­ning. She also saw a num­ber of men­tal health is­sues such as panic dis­or­der, anx­i­ety and one pa­tient who was suf­fer­ing from a sig­nif­i­cant de­pres­sion.

The young GP says there were a few pa­tients that morn­ing who “burst into tears” for rea­sons that were not re­lated to their ini­tial pre­sen­ta­tion and an­other who was strug­gling and needed sup­port fol­low­ing a re­cent be­reave­ment.

Dr Cronin typ­i­cally does con­sul­ta­tions re­lat­ing to women’s health in the af­ter­noon and that day in­cluded re­view­ing a pa­tient in whom she had re­cently fit­ted a Mirena Coil.

She saw al­ler­gies, a uri­nary in­fec­tion, and spent some time with a pa­tient who was re­cently dis­charged from hospi­tal who was con­fused about their dis­charge pre­scrip­tion. This in­volved phone calls back to forth to the hospi­tal and the phar­macy. She also saw an el­derly pa­tient with me­mory dif-

There were a few pa­tients that morn­ing who “burst into tears” for rea­sons that were not re­lated to their ini­tial pre­sen­ta­tion


Through­out the day, Dr Cronin filled out a num­ber of forms in­clud­ing an ap­pli­ca­tion for dis­abled park­ing and two travel com­pan­ion forms. She also in­ter­preted 86 blood re­sults; which in­cluded com­mu­ni­cat­ing re­sults to pa­tients, dealt with the day’s post and made and took seven phone calls re­lat­ing to pa­tient care.

Dr Cronin says she loves her job as a GP, how­ever she adds it is “prob­a­bly more dif­fi­cult than I ever re­ally gave it credit for”.

“We are ex­pected to do more and more with less and less. And I think pa­tients’ ex­pec­ta­tions are higher than they have ever been. We live in a so­ci­ety where ev­ery­thing is in­stant and when you have to ex­plain to some­body who hasn’t got health in­sur­ance – look, you are go­ing to be wait­ing nine months to see a gy­nae­col­o­gist for that fi­broid – peo­ple don’t un­der­stand that, be­cause it is not the way they op­er­ate.

“I don’t apol­o­gise for the sys­tem that we work in, it is what it is and I would make it bet­ter if I could. I think that part is tricky, and it is all about manag­ing pa­tients’ ex­pec­ta­tions,” Dr Cronin adds.

Ea­monn Shanahan

“The vast ma­jor­ity of GPs do a very good job and the vast ma­jor­ity of GPs do gen­uinely care for their pa­tients”

Dr Ea­monn Shanahan has been a full-time ru­ral GP for 31 years in Far­ran­fore, Co Kerry. The prac­tice has been car­ing for pa­tients in the area for al­most a cen­tury, as it was first es­tab­lished by Ea­monn’s grand­fa­ther in 1921. Eam­mon’s fa­ther, Dr Richard (Dick) Shanahan, also worked as a GP in the prac­tice from 1949 un­til 2003.

Dr Shanahan started his day at 8.30am with a prac­tice meet­ing. He then be­gan his morn­ing surgery at 9am which ran un­til 1.30pm and dur­ing this time he saw 15 pa­tients.

The morn­ing surgery com­prised a range of pre­sen­ta­tions and the vast ma­jor­ity of pa­tients had more than one pre­sent­ing com­plaint. These in­cluded se­ri­ous men­tal ill­ness, bron­chi­tis, mul­ti­ple sclero­sis, os­teoarthri­tis, di­ver­ti­c­uli­tis, stress, fi­bromyal­gia, per­sis­tent cough, asthma, over­ac­tive blad­der, rheuma­toid arthri­tis and chronic heart fail­ure. He also saw a pa­tient who was strug­gling fol­low­ing the death of a spouse and an­other who was suf­fer­ing with chronic de­pres­sion.

Af­ter a 20 min­utes for lunch, he spent the rest of break be­tween clin­ics on pa­per­work and phone calls be­fore af­ter­noon surgery com­menced at 3pm.

He saw nine pa­tients in the af­ter­noon, which in­cluded cases of ul­cer­a­tive col­i­tis, work-re­lated stress, epilepsy, a frac­ture and chronic asthma. The Kerry GP saw his last pa­tient at 6.10pm. Be­tween 6.10pm and 8.30pm Dr Shanahan dealt with the post, re­viewed lab re­sults, made a num­ber of phone calls and com­pleted some ad­di­tional paper work.

Ac­cord­ing to Dr Shanahan, over the past 30 years his work­ing day has changed from one where he saw mi­nor episodic ill­nesses and in­fec­tious dis­eases to a sig­nif­i­cant em­pha­sis on the man­age­ment of chronic med­i­cal con­di­tions such as is­chaemic heart dis­ease, di­a­betes, chronic bron­chi­tis and re­nal fail­ure.

“It is the rare con­sul­ta­tion that I will see a per­son with a sin­gle prob­lem. Typ­i­cally peo­ple will have two or three prob­lems when they come,” he says.

Dr Shanahan is a mem­ber of the Coun­cil of the Royal Col­lege of Gen­eral Prac­ti­tion­ers (RCGP) in the UK rep­re­sent­ing the Ir­ish fac­ulty. Speak­ing in a per­sonal ca­pac­ity, he said the GMS con­tract was “grossly unfit for pur­pose” and he fears that Ir­ish gen­eral prac­tice will go the way of the pro­fes­sion in the UK; the fabric of which he says is cur­rently “un­rav­el­ling”.

“I can eas­ily see the same thing hap­pen­ing here. Ru­ral prac­tice, in­ner-city prac­tice is where you are go­ing to see the strains first, there is go­ing to be in­creas­ingly large tracts of the coun­try where it will not be pos­si­ble to eas­ily see a gen­eral prac­ti­tioner.”

With­out the pro­vi­sion of a new fit for pur­pose, chronic dis­ease-fo­cused con­tract, Dr Shanahan sug­gests gen­eral prac­tice in Ire­land would have a life ex­pectancy of ap­prox­i­mately five years. This he said was due to fact that a sig­nif­i­cant num­ber of older GPs were due to retire in the com­ing years and there was a lack of younger doc­tors to re­place them.

“The vast ma­jor­ity of GPs do a very good job and the vast ma­jor­ity of GPs do gen­uinely care for their pa­tients . . . they have a life-long re­la­tion­ship and they re­ally will go the ex­tra mile to do the best they can for their pa­tients in the ma­jor­ity of cases and I be­lieve that ap­plies right across the coun­try . . . the prob­lem is that if we are not there then the re­la­tion­ship can’t ex­ist.”

Mark Mur­phy

“The main chal­lenge is not be­ing able to pro­vide the ap­pro­pri­ate chronic care that pa­tients de­serve”

Dr Mark Mur­phy qual­i­fied as a GP in 2012 and works as a salaried as­sis­tant GP in Dún Laoghaire, Co Dublin.

Dr Mur­phy’s day in gen­eral prac­tice started at 8.30am with a visit to a lo­cal nurs­ing home where he saw 16 pa­tients. Af­ter com­plet­ing the re­quired pa­per­work, he re­turned to the prac­tice at 11am where he saw an­other 10 pa­tients.

He then did a house call to see a pa­tient with a men­tal health dif­fi­culty who was acutely un­well, and called to an­other nurs­ing home.

Be­fore af­ter­noon surgery, Dr Mur­phy ate a sand­wich at his desk as he wrote pre­scrip­tions, re­viewed blood and ra­di­ol­ogy re­ports and dealt with the post.

In the af­ter­noon, he saw ap­prox­i­mately 16 pa­tients from 3pm to 6pm and he left the surgery at 7.10pm af­ter com­plet­ing more pa­per­work.

Dr Mur­phy says the most en­joy­able part of the day is the face-to-face con­sul­ta­tions with pa­tients and this takes up ap­prox­i­mately 60 per cent of his work­load.

Through­out the day, he cared for a va­ri­ety of pa­tients, from an in­fant of two months, to chil­dren un­der 6, ado­les­cents and those aged over 70.

“There is huge va­ri­ety and that is what makes it so re­ward­ing but it is a very busy day.”

Dr Mur­phy says it is a chal­lenge rec­on­cil­ing the lim­ited GP con­tract with the needs of pa­tients with mul­ti­ple chronic con­di­tions.

Out­lin­ing the great­est chal­lenges he ex­pe­ri­ences as a GP in Ire­land to­day, Dr Mur­phy says the first is not be­ing able to pro­vide the ap­pro­pri­ate chronic care that pa­tients de­serve and the sec­ond was what he de­scribed as the “whole­sale inequal­ity” in the health­care sys­tem.

“Only a few pa­tients need to be re­ferred to se­condary care but when they are re­ferred the first ques­tion a GP has to ask them is do you have health in­sur­ance or not? That it is a ter­ri­ble in­dict­ment of our health­care sys­tem, when a per­son’s fi­nan­cial means very much af­fects their abil­ity to ac­cess health care and def­i­nitely af­fects their out­comes. So I think the dif­fer­en­tial ac­cess to se­condary care is very un­equal and that is a ma­jor chal­lenge to GPs be­cause I don’t think we want to work in an un­fair or un­equal sys­tem.”

Austin O’Car­roll

“All the ev­i­dence shows that there is not enough doc­tors in ar­eas of de­pri­va­tion and iso­lated ru­ral ar­eas”

Dr Austin O’Car­roll has been work­ing as a GP in in­ner-city Dublin since 1992.

He started his day at 7.30am with a visit to a home­less hos­tel to see a num­ber of pa­tients. He then re­turned to his prac­tice in Dublin 7 to com­mence his morn­ing surgery. He fin­ished work at 6pm with 15 min­utes for lunch which he had while do­ing pa­per­work and in to­tal saw ap­prox­i­mately 40 pa­tients.

Ac­cord­ing to Dr O’Car­roll, while gen­eral prac­tice has al­ways been a busy job he has no­ticed an in­crease in the amount of pre­ven­ta­tive care pro­vided by GPs. He also es­ti­mates that up to 6 per cent of pa­tient con­sul­ta­tions is taken up with fill­ing out so­cial wel­fare forms and writ­ing let­ters for hous­ing or cloth­ing ben­e­fits, part of which is not cov­ered by the GMS con­tract.

As a GP in an area of high de­pri­va­tion, Dr O’Car­roll cares for a pop­u­la­tion with a very high bur­den of ill­ness: these in­clude those with chronic con­di­tions such as COPD, HIV and hep­ati­tis. For ex­am­ple on the day he recorded, Dr O’Car­roll saw be­tween three and four peo­ple with HIV and the same num­ber again with hep­ati­tis.

That would be very un­usual in any other prac­tice but a daily oc­cur­rence for us, he says.

Ac­cord­ing to Dr O’Car­roll, re­search has shown that the more GPs a coun­try has per head of pop­u­la­tion, the higher the life ex­pectancy and the lower the cost to the health care sys­tem.

“If you lose gen­eral prac­tice peo­ple will die younger and you will have a more ex­pen­sive health ser­vice, so it is crit­i­cal.

“I think we are in fac­ing a cri­sis in gen­eral prac­tice be­cause we are not pro­duc­ing enough gen­eral prac­ti­tion­ers, and the older GPs are work­ing harder and get­ting more stressed. I def­i­nitely am work­ing longer and harder than I did when I started and I know sev­eral doc­tors who have re­tired early.”

Dr O’Car­roll said there was a need to train more GPs and find ways to re­tain them in the ser­vice. He also says the spe­cialty needs more re­sources to deal with chronic care. “That is not into the pock­ets of gen­eral prac­ti­tion­ers – more in terms of pre­scrib­ing nurses, salaried GPs. All the ev­i­dence shows that there is not enough doc­tors in ar­eas of de­pri­va­tion and iso­lated ru­ral ar­eas and we need to con­cen­trate re­sources in those ar­eas be­cause both have so­cial de­pri­va­tion prob­lems – peo­ple who are prob­a­bly more in need of a doc­tor be­cause they are un­health­ier, yet they are less likely to ac­cess a doc­tor be­cause there are just less doc­tors in their area.”

A per­son’s fi­nan­cial means very much af­fects their abil­ity to ac­cess health care and def­i­nitely af­fects their out­comes Mark Mur­phy


Sinéad Cronin and Austin O’Car­roll at their prac­tices in Dublin.


Clock­wise from main: Mark Mur­phy at his prac­tice in Dún Laoghaire, Co Dublin, Mary Favier, who works in Cork, and Ea­monn Shanahan, whose prac­tice is in Far­ran­fore, Co Kerry.

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