Dr. Diarmuid Quinlan:

I thank the committee for extending this invitation to the Irish College of General Practitioners. My colleagues, Dr. John Farrell, chairman of the board, and Mr. Fintan Foy, CEO, are here also. It gives me great pleasure to address the committee this morning. I propose to align my presentation with an overarching proposal, namely, to establish a working group on the future of general practice that would look at the key challenges of the GP workforce and workload. I will also discuss some challenges and practical proposals.

The Irish College of General Practitioners is the professional body for general practice in Ireland. As Mr. Moran said, we have approximately 3,500 GPs in Ireland and approximately 850 GP trainees. General practice is fundamental to delivering timely, equitable access to high-quality healthcare across Ireland. The international evidence is very clear. Healthcare systems with strong primary care have better, more equitable population health outcomes and are more cost-effective. One key factor is that one extra GP per 10,000 of population reduces hospital referrals and hospital admissions.

The overarching strategy we would propose is to establish a working group on the future role of GPs in the provision of community healthcare. This will require engagement of the key stakeholders, namely, Government, the HSE, the Department of Health, the ICGP, the Irish Medical Organisation, IMO, the Irish Medical Council, IMC, and patient representatives. General practice essentially needs a much expanded workforce with the appropriate skill mix, high-quality purpose-built premises and administrative and IT supports to ensure we can deliver high-quality accessible care for patients right across this country. This will require substantial and sustained investment.

Our 2021 and 2022 pre-budget submission called for the establishment of a working group on the future of general practice. Unfortunately, this group has not yet been established. However, we are hopeful the committee would support such a proposal and we encourage it to do so. This high-level working group would work with the key stakeholders to plan and develop the immediate and sustained expansion of general practice in the community.

I will next address the workforce challenges we face. There are multiple challenges and many factors underlying the current unprecedented workforce crisis we face. The ICGP has long voiced that we need a sustained and substantial State investment to meet needs. As Mr. Moran said, the HSE predicts a shortage of at least 1,000, and possibly in excess of 1,660, GPs by 2028. Underlying this is the fact that our population is growing and recently exceeded 5 million people. We have a substantial and welcome increase in people aged over 65 and will have almost a doubling of people aged 85 and over by 2025. While this is really welcome and shows that we are providing very good care to our older patients, it also increases healthcare utilisation. In 2018, the HSE identified that we need an increase of almost 50% in the primary care workforce by 2025, which is only three years away.

General practice is pivotal in delivering healthcare. GPs provide in excess of 29 million consultations in daytime each year and well in excess of 1 million consultations in GP out-of-hours services. General practice has been fundamental in supporting the national response to the Covid-19 pandemic by delivering more than half of the Covid booster vaccinations, which was a key component in keeping society safe and enabling the reopening of our society.

I will now address the challenges that our general practice workforce faces and then outline some very practical solutions. In a nutshell, we have 30% fewer GPs per head of population than England. We have a substantial and long-standing workforce deficit. The Department of Health in 2018 recommended an increase of almost 50% in GP numbers. We have an ageing GP workforce. One in seven, or 14%, of our GPs is aged 65 and over. I anticipate that the majority of these will retire in the next three years. This is coming rapidly upon us.

Approximately one quarter of our GPs are in single-handed practice, especially in rural areas, which presents its own challenges for people living in villages across Ireland. We have insufficient primary care teams, nurses, phlebotomists, healthcare assistants and pharmacists. The workload of general practice is expanding substantially as we have an ageing and frail population with multimorbidity and polypharmacy. We have the capacity and ability in general practice to care for these people but we need more GPs. We also know that increasing GMS eligibility predictably increases GP workload and while it is welcome that people can access their GP more readily, increasing the demand on a constrained service is sometimes counterproductive. The Covid-19 pandemic exposed the fragility of all our health service and, most especially, general practice.

I will now address the components of the solutions we propose. The first of these is the fundamental need for a substantial increase in GPs. We need to train more GPs and the HSE is supporting the ICGP in doing that. The good news is that in 2015, we had 159 GP trainees. By 2021, it was 236, by 2022 it was 258 and by 2026, we anticipate having 350 GP trainees. It brings its own challenges to achieve that but the process is certainly well under way.

We also need to put in place incentives to motivate young GPs to establish in general practice, retain mid-career GPs and support our older GPs to continue in practice. Part of this involves looking at the entire streamline. The development of interns in general practice is necessary. We need a substantial increase in the number of training places in hospitals because general practice is a four-year training programme. That programme has moved into the ICGP but it is a four-year programme. We need to increase the number of training posts in hospitals to allow GPs to train because we do two years in hospital rotations and then two years in general practice. One of the bottlenecks is identifying suitable training posts in hospitals for our young GP trainees.

We also need to recruit GPs to work in rural areas. There are many barriers to GPs working in rural areas, particularly the onerous out-of-hours rotas, incentives to make it financially possible for them to do so, guaranteed locum provision, suitable premises and out-of-hours commitments.

These are all real barriers. Other countries have done this with success. We have a very large rural population and the largest percentage of people living in rural areas across Europe.

Almost half of our practices comprise two GPs and these need specific incentives to make these sustainable in the longer term. This will include built infrastructure, shared delivery of services, shared network of supports, including staffing, locums and nursing support. We need to look beyond our own shores and support non-EU GP recruitment. Non-EU GPs can now apply for training in Ireland and we must accelerate this and support relocation and integration of appropriately qualified non-EU doctors. This is a short-term response to the current severe deficit but we must provide structural and highly supported entry into Irish general practice. This is currently under way in part supported by the HSE.

We have a major shortage of GP nurses in Ireland. Our GP nurses are highly skilled autonomous clinicians and they have a very broad and deep clinical expertise. To give an example, in my practice in Cork we have eight GPs but just one whole-time equivalent nurse. A similar-sized practice in the NHS would have between six and ten nurses and, therefore, we need substantially more GP nurses. We need to look at the career, development and professional structures to enable more nurses to enter general practice and provide them with a career pathway for advanced nurse practitioners, nurse prescribers and clinical nurse specialists to support the fantastic chronic disease management programme that we have. Other countries have done this and NHS Scotland has done a similar programme with great success. We also need far more allied healthcare assistants in addition to nurses and other professionals working with us in general practice.

There is a major paucity of data in general practice. The HSE ICGP Sláintecare research hub is rapidly addressing this strategic deficit. Irish general practice is almost entirely computerised and this will provide us with real-time data. We are seeking a cohort of funded GP-centred practices to provide data on the quantity, quality and quantum of GP activity.

The final matter I want to raise concerns built infrastructure. As Mr. Moran said, this provides a major barrier to young GPs coming into general practice. Society does not expect other healthcare workers to provide their work premises and the bricks and mortar is perceived by many young GPs as a barrier to recruitment, retention, mobility and, ultimately, their retirement. Other countries, including Scotland, have addressed this. We call for innovative solutions and we are certainly open to discussing them. As we expand our GP team, we will need substantially more clinical space, with associated infrastructure costs.

To conclude, we have an overarching proposal, which is the establishment of a working group on the future of general practice in primary in the community in Ireland. This working group will address the workforce and workload challenges I have touched on, including the very substantial shortage of GPs, GP nurses and allied healthcare professionals. We must look at our data and address infrastructure. I thank the committee for the opportunity to raise these matters and I look forward to its questions.