Dr. John O'Brien:

Clear and honest communication around resourcing for mental health care is essential. It is the view of the ICGP that there is an absolute requirement to increase capacity in GP-led health care, including mental health care, within the Irish health system. Three important observations are particularly relevant in this context. First, the numbers of GPs and practice nurses per capita in the Irish health system are low by international standards. The number of GPs per 100,000 population in Ireland is in the order of 64, compared to 90 to 100 in Canada, Scotland and England. There are approximately 3,700 GPs and 1,800 practice nurses working in our system, and these numbers need to be urgently increased towards 5,000 of each as we plan for a population of 5 million in the intermediate term.

Second, the proportion of total health spending on primary care in Ireland is strikingly low compared to developed economies including Canada, Australia, Scandinavian health systems and the NHS in the UK. In those health systems, about 8% to 11% of total health spending is directed into primary care, whereas in Ireland the proportion is 4%.

Third, the overall spend on health care in Ireland is in the order of €20 billion to €22 billion, and the per capita spend here is high by international standards. It is the view of the ICGP that within the Irish health system, we are historically spending excessively on hospital based care, administrative overheads, technological medicine, specialised care and pharmacological therapies. Conversely, we are spending too little on primary care and on holistic talking therapies.

Irish general practice is leading the Irish health system in the use of electronic medical records. Despite low levels of funding for primary care, most Irish citizens can access a GP on demand, or within a day or two.

Most Irish people still believe they have their own GP and have an appreciation of personal care. The ICGP, Irish College of General Practitioners, however, is of the view that better and higher volumes of care could be provided by increasing capacity in GP-led care. Recruitment and retention of more GPs would enable higher volumes and better quality of care in communities, including mental health, enabling better prevention, earlier diagnosis and better community-based care.

Irish general practices are slowly getting larger. The proportion of singlehanded GPs is now at 18%. As more GPs work in practices with three, four, or more GPs, these larger practices could usefully incorporate an on-site strand of talk therapy, delivered by GPs, practice nurses and visiting allied professionals such as counselling psychotherapists. Trend-setting practices are actively exploring the use of relevant innovative care including telemedicine, mental health and exercise apps, as well as social prescribing.

While turnover in general practice teams is low with good continuity of care, it is not the case in public psychiatry care where high levels of turnover are understood to be a problem. This creates special difficulties in psychiatry where communication and continuity are particularly important.

I want to take a clinical case scenario to highlight how general practice might run in mental health care provision. Mary is depressed. She attends her GP and she frets in a busy waiting room. She sits with an agitated man who explains he has diabetes, a mother and a baby with a cough, a gentleman with pain, as well as two other women, one of whom is clearly pregnant. Mary is anxious but it helps that she is attending her own GP, hers since she was a child. She likes him because she feels known and heard. Her GP is careful with her. Mary explains she is tired all the time and gets headaches. He listens as she describes that the headaches occur most days, she feels exhausted, cannot do things with the children and feels guilty all the time. The GP asks what she thinks might be going on. She is not fully sure but, on reflection, they both agree things are not that good in her relationship. She has three children under ten, she works outside the home and also visits her mother with whom she has a complicated relationship, who is ill and needs her attention. She knows she has increased the amount she is drinking but finds the only nights she gets a few hours of decent sleep are when she has had three or four glasses of wine, which is now happening four or five nights per week. She is worried she has a serious illness, maybe a brain tumour. How would the children cope? She is tearful and needs time to compose herself as she tells her story.

The GP evaluates the headache, does a neurological examination and measures blood pressure. She says the pleasure has gone out of her life, she feels mostly hopeless and worthless but is not suicidal. Blood pressure and examination are normal while mental state examination is consistent with mild depression and anxiety. These findings are shared and, together, they make a plan. She will reflect on the main causes of exhaustion, undertakes to get back to Pilates and go for a 30-minute walk most days. She thinks her brother can visit her mother for the next three to four weeks. She undertakes to reduce alcohol to one night per week. Bloods are arranged to check for hypothyroidism, anaemia, diabetes, liver enzymes and a menopause profile. A review is planned for two to three weeks. The GP outlines what might help such as exercise, mindfulness - the GP suggests a mindfulness app - counselling and also medication. The GP explains that medication is neither good nor bad but just one of the tools for getting out of a depression. She is nervous of medication, fearing addiction or that it may alter her personality. The GP is sure she will get back on top, having previously assisted when she had a moderate depression after the birth of her second child. This all takes between 22 and 30 minutes. It is a long consultation and this is where the pressure of time plays out.