If you need a doctor this bank holiday weekend, what are your chances of finding a GP? Eithne Donnellan reports
It was the night before New Year's Eve. Irene Donovan had a pain in her chest. She also had a very high temperature and was vomiting every 10 minutes. Her husband called the family doctor.
Being holiday time, their GP was off but had left a number on an answering machine for patients to call in the event of an emergency. The Donovans called the number and the person who answered said a doctor would be sent to their home in Kinsealy, north Co Dublin, as soon as possible.
Hours passed and there was still no sign of a doctor. Irene's husband called the emergency number again. The reply was the same. The doctor was busy but would get to them as soon as he could.
"He eventually came to the door 7½ hours later," recalls Irene. "You would imagine it would be an hour, two hours at the most.
"He was a very nice doctor. He gave me an injection and prescribed antibiotics and diagnosed a kidney infection."
But she couldn't believe in the 21st century she would have to wait so long for a doctor to make a house call. She had opted to call a doctor out that night rather than go to A&E because of all the stories of chaos in emergency departments. In addition, she says, she wasn't well enough to get up and travel to A&E. She would have had to call an ambulance eventually if the doctor hadn't turned up.
"I remember lying in bed sick, praying that the next car that came around the corner was the doctor. It's an awful feeling to be sick and to have to worry as well about when the doctor will come," she said.
The reason the Donovans had to wait so long for such a service out of hours is because they live in north Dublin where there are GP shortages and where efforts to set up an out-of-hours GP co-op have so far failed.
There are many areas across the country where families have a completely different experience, where those who call out family doctors at night, at weekends or on bank holidays can have somebody knocking on their doors in less than 30 minutes. This is especially the case in small rural towns where GPs cover for each other on a rota basis and where GP co-ops have been established.
An estimated 40 per cent of the population is now covered by GP co-ops, and where patients who have used these have been surveyed, the satisfaction ratings have been very high.
Dr Donal Coffey, chairman of the Irish Association of GP Co-ops and a medical director and founder member of South Doc - a GP co-op covering Cork city and county, and many parts of Kerry - says satisfaction ratings have been as high as 98 per cent.
There are, he says, around 400 GPs who have signed up to South Doc. It swings into operation after hours, and any person in the region needing a doctor after 5pm in the evening on weekdays or at weekends can call a 1850 number.
The calls are logged in Killarney and a triage nurse will, over the telephone, advise the patient what to do. If the patient needs to be seen at a local treatment centre, a doctor will be there to meet them, and if they need a house call a doctor will be taken to their house by a dedicated driver. If a patient is very unwell the co-op may organise for an ambulance to be sent to their home to take them to hospital.
There are at least 21 doctors on duty at any one time and the region has 18 different treatment centres, which can be used after hours.
"It works very well. The satisfaction rates are astounding really. I don't see them replicated in any other part of the health service," Dr Coffey says.
"Nobody should turn up in A&E now saying they can't get a GP where there are co-ops," he added.
South Doc, he says, sees an average of 2,800 patients a week and less than 2.5 per cent of these are referred on to A&E. The Health Service Executive (HSE) pays for the triage nurses and call-centre staff as well as the co-op cars and other infrastructure. The average annual cost to the executive for each patient seen in the south is €12. "It is getting huge value for money," Dr Coffey argues.
The doctors who provide the out-of-hours service for the co-op are, in the case of people without medical cards, paid directly by the patients. And most of the doctors working out of hours for this co-op are GPs from the area working overnight on a rostered basis. However some of the graveyard shifts - known in the business as red eye shifts - are farmed out to agency doctors, brought into the country from Australia, New Zealand, South Africa and other parts of the EU by a private company called Locomotion.
This agency also provides doctors to do red eye shifts for co-ops in the south-east, the north-west and north-east, according to its general manager, Rebecca Drummond. "A lot of them come in and do three or four nights a week for a co-op and stay for six weeks," she says.
MANY OF THE other co-ops work more or less in a similar fashion to South Doc, but in the north-east patients calling the co-op NEDoc are triaged by doctors.
Another huge co-op is Caredoc, covering a population of around half a million across counties Carlow, Kilkenny, Wexford, Waterford plus south Tipperary and south Wicklow. It handles an average of 3,300 out-of-hours calls per week and after patients are seen out of hours the details of their diagnosis and treatment are sent to the patients' own GPs the following day.
Overall there are eight GP co-ops across the State with full call-centre and triaging facilities. But there are also a number of smaller co-ops set up by GPs in south Dublin, including East Doc, DL Doc and Luke Doc, which operate from 6pm to 10pm weekdays and from 10am to 6pm on Saturdays, Sundays and bank holidays. Outside these hours patients are asked to contact their own GPs.
In the eight areas covered by full co-op services, patients should have no difficulty getting to see a GP on this or any other bank holiday weekend.
But Sheila O'Connor of Patient Focus says her organisation receives calls "all the time" from patients who cannot get a GP at the weekend. "It's not just a Dublin issue. People end up going to A&E as a result. It's most definitely a factor in A&E overcrowding," she says.
The HSE stresses that each GP who holds a GMS contract (a contract with the State to treat medical card holders) "is obliged to make arrangements to enable contact to be made with them or their locum/deputy outside normal hours for urgent cases".
In areas such as Dingle and Westport, GPs discharge this duty by working rotas drawn up among themselves to avoid a situation where they would all be on call all of the time.
THIS LUXURY ISN'T available to GPs on the Aran Islands, however. There is just one GP on Inis Mór and just one GP covering Inis Meáin and Inis Oír. They are both on call 24 hours a day, like all GPs were years ago. At the annual conference of the Irish Medical Organisation (IMO) in Killarney last week both Dr Marion Broderick on Inis Mór and Dr Maura O'Meara, who covers the other two islands, urged the HSE to provide them with greater support.
Dr Martin Daly, the chairman of the IMO's GP committee, says the best service any patient could get would be having their own GP available 24 hours a day. "Many generations of GPs provided that type of cover but it is simply unsustainable in the modern era where there are such high expectations of day-time service and where younger GPs have an expectation to have rest time in which to develop their own families and social lives," he says.
When, as he puts it, people talk about "the good old days" when their own doctor was always on call they forget there was a huge price to be paid by those doctors and their families.
He says the future lies in co-ops, and while talks on the setting up of a GP co-op in north Dublin fell apart earlier in the year the negotiations have now recommenced and "substantial progress" was made at a meeting between the HSE and the GPs in the area, facilitated by the IMO, last Wednesday.
Dr Daly is part of WestDoc, which covers Galway city and parts of counties Galway, Mayo and Roscommon. "The average time from making contact with WestDoc to being seen is 21 minutes. It would be difficult to improve on that," he says. "These co-ops need to be encouraged and invested in. Otherwise we may well experience the chaotic situation as pertains in the UK."
In the UK, GPs were allowed to opt out of providing out-of-hours cover when they negotiated new contracts just over a year ago. It has resulted in a situation where just 10 per cent of GPs are now providing out-of-hours cover and the NHS has had to fly in foreign doctors, at huge cost, to provide the rest.
Dr Daly says the IMO was coming under increasing pressure from older doctors, as well as young female members, to seek a derogation from providing out-of-hours cover in the context of current negotiations on a new GP contract.
Prof Tom O'Dowd, professor of general practice at Trinity College Dublin, has a firm view on why it isn't always easy to get a GP after hours. He says there have been years of under-investment in primary care. Politicians, he says, were only interested in being photographed outside new hospital developments. "Now the chickens are coming home to roost."
"I did out of hours for years and years and it's very tough work . . . but doctors are changing and patients are changing," he says.
Patients, who themselves are now working longer hours, expect their doctors to do the same, Prof O'Dowd comments. But consultations with patients during the day are now much more intense than they used to be, he says, and a doctor couldn't safely work all day and all night any more.
"The State has largely ignored general practice and its capability and they are now looking to it to sort out their problems. There has been lack of investment . . . we were told the primary care strategy was the only game in town and what a miserable little game it has turned out to be," he says.
THE PRIMARY CARE strategy, published in 2001, promised huge investment in general practice, much of which never materialised. However, additional funding was provided in last November's estimates for the extension of GP co-ops to about 70 per cent of the population.
Prof O'Dowd is optimistic that Prof Brendan Drumm, who took over as head of the HSE last year, will bring change. He has appointed a founder of GP co-ops to his team of advisers. "I do think that GPs in general feel that Brendan Drumm understands them and what they can and can't do . . . I think GPs do trust him," he says.
He stresses that while Minister for Health Mary Harney has been talking about GPs working longer hours, particularly since it emerged that thousands of patients are self-referring to A&E units, the reality is that about 70 per cent of the time GPs have no obligation to work for the State. During this time they are seeing patients who do not have medical cards.
"It's a private business. Having the Minister roaring and shouting really doesn't concern many GPs, I would have thought, because they are their own bosses. I suppose it would be a bit like shouting at Spar and Centra for not supplying bread in the middle of the night. It's not going to put more bread on the table," Prof O'Dowd says.
He acknowledges, nonetheless, that even if GPs are their own bosses they have "a duty of care" to their patients around the clock and must ensure that if they are not available an alternative out-of-hours service is provided.
"People do find it difficult to get services out of hours. It has to be faced up to . . . Certainly the next year or two should be a time when we devote a lot of ingenuity to solving the problem and part of that is expanding the co-ops," he says.
"I think the problem is GPs are not putting themselves on the line in the self-sacrificial way that they used to. Doctors are being more careful about not working beyond the point of endurance and they are entitled to do that."
Dr Coffey says it is "ridiculous" that anyone should have to wait more than seven hours for a GP at night. "In a co-op situation that would be regarded as a failure of the system and it would be investigated."