General Practice in Ireland

General Practice in Ireland: A Comprehensive Overview (RCSI)

FFP1 Module Learning Outcomes

These notes address selected FFP1 Module Learning Outcomes, focusing on the Irish healthcare system, primary care, and general practice:

  • Use effective strategies (e.g., communication, collaboration, interventions) as part of a team.

  • Describe global trends in morbidity and mortality using Global Burden of Disease study data (tangentially addressed by discussing national health system challenges).

  • Discuss the application of professionalism, leadership and resilience (i.e. the constructs of Personal and Professional Identity) to manage self and engage with patients, colleagues and communities.

  • Describe the social determinants of health and the breadth and function of the public health and health promotion role (addressed through discussion of health access and equity).

Lecture Learning Outcomes

The primary objectives of this lecture are to:

  • Discuss the structure and access to the healthcare system in Ireland.

  • Outline what primary care is and how patients access this care.

  • Discuss General Practice and how it fits into the healthcare landscape.

The Health Service in Ireland

Structure of Healthcare Services

The Irish healthcare system is structured in a tiered approach:

  • Self-care: The foundational level where individuals manage their own health.

  • Primary care: The first point of professional contact for most health needs.

  • Secondary and tertiary care: Hospital-based specialist care.

Definition of Primary Care

Primary care is an approach that encompasses a diverse range of services, designed to maintain well-being throughout an individual's life. It includes:

  • Health promotion and disease screening.

  • Assessment, diagnosis, treatment, and rehabilitation.

  • Personal social services.

It serves as the first level contact, emphasizing easy accessibility and a strong focus on collaborative efforts with communities and individuals to enhance their health and social well-being. While often used interchangeably with 'general practice' (GP) or 'family medicine', primary care also includes other essential services.

Primary Care Teams

Primary care is delivered by multidisciplinary teams, which may include:

  • GP

  • Nurse/midwife

  • Healthcare assistant

  • Home help

  • Physiotherapist

  • Occupational therapist

  • Social worker

  • Receptionist

  • Clerical assistant

  • Administrator

  • Podiatrist

  • Community welfare officer

  • Community pharmacist

  • Dentist

  • Dietitian

  • Psychologist/therapist

  • Speech & language therapist

Access to Healthcare in Ireland: Primary Healthcare

Access to primary healthcare in Ireland is characterized by a two-tier system, affecting the eligibility for free or subsidized care.

Medical Cards

  • Eligibility: Primarily means-tested. Some discretionary cards are granted based on 'exceptional' medical need.

  • Benefits:

    • FREE GP care (including out-of-hours services).

    • FREE primary care services (though waiting lists and service unavailability can be issues).

    • FREE medications (a small prescription charge may apply).

  • Population Coverage: Accounts for approximately 35 ext{\char37} of the population's primary healthcare eligibility.

GP Visit Cards (General)

  • Eligibility: Means-tested, available for ages 8-69.

  • Benefits:

    • FREE GP care (including out-of-hours services).

    • Patients still PAY for other primary care services (e.g., physiotherapy).

    • Patients PAY for medications, but a maximum charge of €80/month per family applies under the Drug Payment Scheme.

  • Population Coverage: Accounts for approximately 10 ext{\char37} of the population's primary healthcare eligibility.

GP Visit Cards (Specific)

  • Eligibility: Automatically granted to specific categories, including those under 8 years old, over 70 years old, and carers. There are ongoing expansions to other population categories.

Private Patients

  • Eligibility: Individuals who do not qualify for Medical Cards or GP Visit Cards.

  • Costs:

    • PAY for GP care, typically costing €45-80 per consultation.

    • PAY for other primary care services.

    • PAY for medications, with the same maximum charge of €80/month per family under the Drug Payment Scheme.

  • Population Coverage: Accounts for approximately 55 ext{\char37} of the population's primary healthcare eligibility.

Secondary Care

Types of Hospitals

  • Public Hospitals: State-run through the Health Service Executive (HSE).

  • Voluntary Public Hospitals: Primarily state-funded but may have private ownership or management.

  • Private Hospitals: Operate without state funding.

Access to Public Hospitals

  • Emergency Department (ED):

    • €100 fee for private patients resident in Ireland (with exceptions).

    • No fee for Medical Card or GP Visit Card holders.

  • Referral from GP:

    • ED (if emergency): No fee for private patients.

    • Outpatient Clinic (OPD): No fees (for public patients). Patient may be admitted as a "public patient" with no fees for in-patient stay.

    • Private Patient Admission: Fees apply and are usually covered directly by health insurance companies.

General Practice in Ireland

Overview and Workforce

  • Approximately 2500 GP practices operate across Ireland.

  • There are roughly 4000 GPs currently practicing.

  • About 200 GP trainees complete their 4-year specialist training program annually.

  • 350 trainees are expected to commence their 4-year program in 2025.

  • A significant challenge is the projected retirement of approximately 700 GPs within the next 5 years.

  • The GP workforce exhibits a roughly 50:50 gender split.

Practice Settings

  • Most GPs work in group practices, with clinics (surgeries) located in:

    • Health centres.

    • Primary care centres.

    • Purpose-built buildings.

    • Converted houses.

  • Some single-handed practices still exist, though they are less common.

Characteristics of General Practice (Barbara Starfield's Four Central Features)

Barbara Starfield identified key features essential for effective primary care:

  1. First Contact: General practice serves as the initial point of contact for all patients across all their care needs.

  2. Continuous Care: Emphasizes person-focused care, rather than solely disease-focused, provided consistently over time. This fosters continuity of care.

  3. Comprehensive: GPs provide care for all common health needs within the population.

  4. Coordination: General practice plays a crucial role in coordinating a patient's care across different services and specialties.

A Typical Morning in a Doctor's Clinic (Example Scenario: 8.45am)

This exemplifies the variety and complexity encountered in general practice:

  • Daily Patient Load: A GP typically sees 25-30 patients per day.

  • Consultation Time: Approximately 12-15 minutes per patient.

  • Variety of Presentations: Patients present with a wide array of complaints, from chronic illness follow-ups to acute symptoms, immunizations, mental health concerns, sexual health, minor procedures, and antenatal care.

  • Patient Relationship: All patients seen are generally known to the GP, fostering continuous care.

  • First-Time Patients: GPs also manage cases where patients are presenting to the healthcare service for the first time.

  • Managing Ideas, Concerns, Expectations (ICE): A crucial aspect of GP consultations involves understanding and addressing patients' individual ideas, concerns, and expectations about their health.

  • Interventions: In the example given, a minority of patients required further investigations, and only one referral (to physiotherapy) was made, with no referrals to the hospital.