About me

1. About me • Graduated UCC • Cork GP training scheme • Trainee year in Rosscarbery • 5 years in Listowel • Clonaslee since 1990. • Village of 500 people 8 miles from Tullamore. Local industries are forestry and farming. Most people commute to work in Tullamore, Portlaoise or Dublin. • Foot of the Sliabh Blooms. (great walking) • Chair of ICGP since May 2013

2. The plight of Rural General Practitioners • Defining Rural • Demographics of GP workforce. • What is different about Rural practice • Are rural doctors different • Impact on families • Impact on doctors • Accessing CME and Professional Competence (ICGP role)

3. The Plight of Rural General Practitioners • Financial stresses • Female rural GPs (are there different issues) • Succession Planning (Attracting new doctors) • Retiring • Are there solutions?

4. What is rural? • Even within an area as small as Ireland, there is a huge diversity in terms of the nature of rurality. Commonly agreed features might include, for example, a scattered population, community atmosphere, strong local networks and limited local employment. But the spectrum varies greatly. It can range from remote islands and boglands, where rurality can be defined easily by land use, to small rural commuter villages close to urban centres, where rurality is more of a social construct. In other words, developing a measure of rurality to apply across the country is particularly difficult.

5. GP DemographicsTeljeur, Odowd, Okelly & Thomas TCD 2010 • There have been substantial changes in the age, gender and work patterns of GPs in Ireland over the last 25 years . • Graduates increasingly favour flexible hours and earlier retirement. Concern has been expressed that if trends continue there will be serious problems with the availability of GP services over the next decade. • The existing workforce is 44% female compared to only 15% in the early 1990s. The mean age of GPs is 47.8 years. • Fifteen percent of GPs are over 60 (ie. 1 in 6 will retire by 2020 )and the vast majority of older GPs are male. • The percentage GPs in rural practice has declined from 33% in the early 1990s to less than 22% in 2005 Much of the decrease in rural practice has translated into an increase in GPs in a mixed urban/rural setting. • Rural practice accounts for more than a third of GPs over 60.

6. DemographicsMedical Council figures 2012 • GP density 44.3/100,000 population • Fulltime 75.4% • Proportion of GPs who are female 44.7% • GPs over 45 …66% male • GPs under 45 68% female • Female doctors twice as likely to work part-time • Current shortage of GPs is likely to worsen as the population ages with increasing demand on services • Medical council figures do not look at urban rural distribution

7. Social and family issues of rural practice • Fewer employment opportunities for a GP’s spouse or partner • Housing less plentiful and less marketable • School choices limited although rural schools are often good • Local retail and service industries are limited and expensive • Limited access to professional cultural and sporting occasions • Lack of privacy: intrusion, gossip and unreal expectation of availability • Lack of confidentiality if ill, marital issues etc

8. Social and Family issues • Difficulty ensuring family time “we and me time” • Problems with locum cover for holidays, educational leave and sick leave • Locums staying in your house when you do find one.

9. Cost of providing service • Most evidence indicates that the direct costs of providing services in rural areas are higher than in urban areas. (Wollett, 1990). • Factors include: • lack of economies of scale • additional travel costs • additional telecommunication costs • high level of unproductive time (getting from A to B and house calls) • extra costs of providing mobile and outreach services • extra costs of training and other support. • Reduced opportunities for other work (teaching etc)

10. Costs of providing service • Effect of loss of GMS distance coding has had greater effect on rural practices • Rural GMS patients likely to be older with greater effect on practice support subsidies with the reduction of weighting. • Growing GMS lists= falling private patient numbers • Static or falling population in rural areas. • Essential costs of practising, indemnity, staff pay, registration, rent/mortgage, motoring are all increasing.

11. Practicing in rural area • Challenging and Complex • Increased chronic disease management • Greater variety • More likely to carry out procedures, suturing etc • More emergency work, longer waits for ambulance service = need for extra equipment • Onerous rotas • Professional isolation • Poorer access to broadband, mobile phone coverage • Difficulty of looking after friends

12. practising in rural areas • Poorer infrastructure, roads and transport

13. Practicing in Rural areas • Other difficulties largely stem from the lack of freedom, for doctor and patient, inherent in living in remote areas. It can be difficult to look after patients who have become close friends, especially during serious illness. Small communities can be claustrophobic and lonely, especially when everyone is a patient. Most are wonderful rumour factories. Anonymity is impossible. If the doctor is unfortunate enough to become ill or have an alcohol or marital problem, then access to confidential medical care can be very difficult. Many remote practices are single handed, and professional isolation is a real problem • (John Gillies)

14. It’s different for women • New Zealand survey of 559 GPs • Of the 338 rural GPs who fulfilled the inclusion criteria, 93 (28%) were female. Eighty percent of female rural GPs were younger than 45 years of age compared with 53% of male rural GPs • Women were less likely to be in full-time practice (45% vs 90%) or own their own practice (63% vs 83%) • Concerns about locum scarcities, overwork, excessive on-call, bureaucratic demands, and GP shortages were equally important to both genders—while issues of security, accreditation, and combining work and family were mentioned by female GPs.

15. Different for women • Women often have cyclical and interrupted careers, which reflect their other roles, especially as mothers, • They often see a different profile of patients and problems. More complex psychosocial problems •  more female GPs expressed concern about the impact their job was having on the family. Additional related issues such as childcare, children’s education, opportunities for spouses, juggling on-call duty with family responsibilities, and being able to spend holidays with family were only mentioned by women.

16. Different for women • A study of 1800 GPs in England found that the most significant predictor of female GPs’ mental health was the stress of the job interfering with family life, which was the least important predictor for male general practitioners. • This issue is magnified in rural practice where female GPs also juggle the demands of long hours, on-call duty, and lack of locum relief for holidays or study breaks. Similar findings have been found in other studies of female rural general • This unique gender difference of female GPs, in having cyclical and interrupted careers due to their other roles, especially as mothers, needs to be acknowledged and valued.

17. GP as patient

18. Physical illness • Difficulties with locum cover, locum cover, locum cover. • Most of us have gone to work when we would have told a patient with a similar illness that they were unfit. • How many of us have a GP? • How many of us self diagnose and self medicate. • Financial cost of being ill as a self employed business person

19. Mental health issues • (Australia “Beyond blue” Mental health of doctors) • Rates of depression similar to general population. • Substance misuse, alcohol similar to general population, Benzodiazepines higher. Self medication, easier access • Suicide rate in male doctors 26% higher than • general population • Suicide in female doctors 146% higher. • Help seeking rates low. Significant proportion would not seek help for depression

20. Barriers to help seeking • Concerns about stigma • Impact on colleagues • Impact on patients • Concerns about confidentiality • Embarassment • GPs concerned about impact on practice.

21. GP as patient • We are not good at being patients • How good are we at looking after other doctors? • ICGP Health in practice programme is a primary care model with direct access to a telephone helpline, GPs, psychological therapists and occupational health physicians. We also have a list of psychiatrists who are linked and can be referred to from GP. The key is all these networks are comfortable and experienced in dealing with doctors and their families as patients. • Confidential service

22. Collegiality and support • We often notice absence • Perhaps a text saying “noticed you weren’t at.. How are things?” • Declaration of Geneva (physician’s oath) 1948 includes the phrase “my colleagues will be my sisters and brothers”

23. Succession and retirement • Difficulties in attracting younger doctors to rural and especially remote areas. • Anecdotal reports of small interest/no interest in rural GMS lists. • Government incentives and inducements required to attract and retain doctors in rural practices. • Different contracts? Eg Part-time contracts, Job sharing, Salaried posts. • Improved co-op cover • Retention of recently graduated GPs. • Improvement in infrastructure.

24. problems with access to CME / CPD • Locum cover, locum cover, locum cover • Professional isolation • Poor broadband coverage • Cost of courses (financial and personal time) • Geographical isolation • More onerous rotas in rural areas. Harder to get time off. • Increasing demand because of Mandatory CPD • Increasing demand on CME group structure

25. How ICGP is trying to help • Reduction in Membership fee (down €200) Professional competence fee is fixed by Medical council. Reduction in fees is >80% of this professional competence fee • Reduced membership fee for doctors who work part-time • Development of free E-learning modules for members • Recruitment of replacement CME tutors. 4 posts advertised last month. • Recruitment and training of group leaders to increase number of groups managed by a CME tutor and hence increase access to groups • New course ideas. We are always open to new suggestions for courses.

26. Why do we keep doing what we do? • What is good about rural practice? • Challenging varied work • Holistic care of patients • Feeling valued • Being part of a community • At the end of the day I think Steve Jobs said it better than I could…