Two years ago, general practitioner Dr Ciarán Ó Fearraigh bucked a trend among doctors: he moved from a multi-doctor practice to a single-handed one in Co Donegal.
The Ramelton Health Centre was a long-established practice, but the principal doctor was retiring and Ó Fearraigh was conscious that had he not taken over, there was a very real risk of locals being without a GP in the town, located a 20-minute drive from Letterkenny.
“That’s part of the challenge in some of these remote and rural practices where they haven’t been able to find a replacement. In that case the HSE has to find locum cover or the practice closes down and people have to travel further to attend the GP,” he says.
“Making sure that the right supports are there so people want to come and work in these rural practices is really important.
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“These practices provide an invaluable service to patients, and it’s not always practical to tell people to travel to neighbouring practices. And neighbouring practices are probably already full and at capacity.”
But this phenomenon isn’t only a problem in Donegal and Ó Fearraigh’s situation is far from being an outlier.
GPs are at the front line of community healthcare in Ireland. There are 4,900 GPs practising in Ireland. About 80 per cent of people visit a GP at least once a year.
On average, there are 21 million doctor consultations and eight million nurse consultations taking place every year in general practices.
Some parts of the country have greater access to these services than others.
Analysis of the workforce data shows Monaghan has the lowest GP coverage per capita, with 50-52 GPs for every 100,000 people in the population, followed by Roscommon (59 to 61 per 100,000), Kilkenny (64 to 66 per 100,000) and Meath (67 to 69 per 100,000).
Sligo has the highest GP coverage per capita, with a range of 121-125 per 100,000, followed by Westmeath at 115-120 per 100,000 and Galway at 105-109 per 100,000.
The analysis from the Irish College of General Practitioners – the official training and professional body for these doctors – published in March,shows three “emerging pressure points” for the future of GP care in Ireland and acute shortages in a number of locations around the country.
The first is rural and remote areas, particularly along the western seaboard. According to the analysis, the challenge here comes from low population density, older patients and ageing GPs.
Data on the workforce shows older GPs are more likely to be men and younger GPs are more likely to be women. Two-thirds of GPs who are under 45 years are women.
A significant number of GPs are approaching or past retirement age. According to the data, 13.5 per cent of GPs are aged 65 or older and 5.9 per cent are 70 or older. Under the State-funded medical card scheme, GPs must retire by the age of 72, though doctors can continue working in private practice as long as they wish so long as they are still fit to practise.
The second pressure point is in the suburban commuter belt around the Greater Dublin Area. Patients across Kilkenny, Meath and Kildare face significant challenges in timely access to GP care, according to the analysis.
Population growth in these areas is “particularly strong and sustained”, the college’s analysis found, but this “significantly exceeds” the expansion of general practices, primary care centres and the number of GPs.
The third challenge for patients arises in urban areas where there are high levels of social deprivation.
“Patients in these areas experience complex multimorbidity, have significantly greater healthcare needs, and develop chronic disease a decade earlier than patients in more affluent areas. These factors increase the workload of GPs,” the analysis finds.
Ó Fearraigh’s rural location along the western seaboard means he is one of those offering services in these pressure points.
“The town I’m in it wouldn’t have the population to support a large, group practice but it very much can support a small practice,” he says.
For him and most single-handed GPs, it can be very difficult to establish a work-life balance or to get any meaningful time off without having adequate supports in place.
“Maternity leave isn’t easy to get cover in those areas. Trying to get short-term leave is very challenging – you’re on your own; you’re a bit exposed in those practices so it can be difficult for people to come there and provide that care,” he says.
Ó Fearraigh says that in his area the older population is spread out and has “high care needs”.
“That comes with some challenges but also some great opportunities and a lot of what that provides is what I love about my job,” he says.
“You’re providing that cradle-to-grave service.”
He typically works 9am-6pm, Monday-Friday, but “typically” goes in on a Saturday and spends some time on paperwork.
“There’s a huge amount of paperwork and admin associated with patient care and running a practice,” he says.
The practice has about 2,000 patients, of which about half have a medical card.
It is open to new patients within his local area, but he cannot accept every new person who seeks to become part of the practice. His practice has increased by about 300 patients since 2024.
“Because I am near Letterkenny, there was significant unmet need there because of pressures, and I was getting a lot of requests from further afield and that was challenging to accept those requests,” he says.
“I was accepting them for the first year but now I try and limit that. It’s very difficult.
“I’ve seen people coming who are pregnant and needing maternity care, and I haven’t left anybody in the lurch but when you reach the capacity point, it’s difficult because you need to meet the needs of your patients.”
But what exactly is driving these pressures?
According to the Irish College of GPs, there are many reasons for increasing demand for GP care. They include an ageing and growing population, people with multiple health conditions,patients needing multiple medications, the expansion of State-funded care under the medical card scheme and the ageing profile of GPs that can lead to gaps in GP cover when doctors retire.
The population of the State is expected to rise above 5.8 million by 2030, on top of a 9 per cent increase over the past five years.
On top of that, the State has one of the longest life expectancies in the European Union. Older people tend to have higher rates of multiple illnesses and see GPs more frequently than younger people. This is having a real impact on access and care.
According to GPs, many patients report having to wait several days for an appointment, though many doctors try to keep slots available each day for those who need it most.
Other patients report being unable to register with a local GP when they move to a new part of the country as doctors insist their practice lists are full.
In a bid to meet demand, the workforce in general practices has increased by about 10 per cent over the past five years, to 4,900, but this is not enough, the college warns.
“The GP workforce is expanding but cannot meet current patient healthcare needs,” it says.
Research from State think-tank the Economic and Social Research Institute (ESRI), last year suggested at least 940 additional GPs will be required to meet expected demand over the next 15 years.
Steps are being taken to increase these numbers further, with the college of GPs, the HSE and the Department of Health putting a programme in place.
Currently, the GP training programme has an annual intake of 350 students every year, but a further expansion of the scheme is promised, bringing the total annual intake to 400.
Adding to this, there is also the international medical graduate rural GP programme designed to tackle the shortage of GPs in rural areas.
The programme recruits and integrates experienced, non-EU doctors into rural practices, providing supervised practice, continuous mentoring and a route to specialist registration.
There are more than 200 GPs serving rural communities across rural Ireland who have completed or are participating in this programme.
In the meantime, GPs and patients are continuing to feel the squeeze.
Along the Dublin commuter belt, Deirdre Collins, a GP in Kilcullen, Co Kildare, says there are 3,500 people in the town in which she works, but she serves a wider hinterland and often cares for patients living near other urban areas such as Naas and Newbridge.
“There is a concern about people having to travel distances to access care. We are open at the moment to taking on new patients in general but we would be conscious of the fact that if we take a patient from too far away, they’re quite far away from us,” she says.
The practice encourages people “to stick with the town they’re with as much as possible but I would certainly be aware of people saying they can’t get someone locally,” she says.
“We’ve had building booms in commuter towns. That’s starting to happen again. That’s something that we as a practice are starting to think about in terms of how many doctors we have available and how many slots we have available.”
The four-doctor practice Collins works in carries out a considerable amount of acute care and emergency care, but she says what people want from the health service has changed and preventive care is increasing.
“That changes the day greatly. People come in with quite a few things that you’ve got to manage. Patients’ needs and what they want from their doctor has changed,” she says.
“We are now managing things that are much more complicated than we were before.”
Care must be of a high standard, says the experienced GP, regardless of the pressures on the system.
Many patients book in for appointments but some slots are left open for emergency care, although she says that “capacity can be difficult”.
Collins says the practice works on the principal of ensure patients get “10 or 15 minutes of good time” and not “two minutes of bad time”.
“So there are times where you have to say: ‘We just cannot see any more people today safely,’” she says.
