Dr. Laura McDonnell on GPs and the evolving healthcare landscape

I always knew I wanted to live and practice rurally, and during my GP registrar year, my passion for family medicine was nurtured.

My GP trainer – Dr. Michael Smyth – was one of a few remaining single-handed GPs and instilled in me a true respect for the value of continuity of care.

Patients of the small village practice were equally appreciative of seeing a doctor who knew them and their families ‘inside out’.

Those halcyon days had sacrosanct ‘whole team’ tea-breaks around a cosy kitchen table, and lunchtime home visits to farms – reminiscent of an episode of ‘All Creatures Great and Small’!

Long before the advent of GP Federations, Dr. Smyth and his colleagues had recognised the importance of collegiality when they established the Fermanagh GP Association.

This fostered close links between primary and secondary care and lunchtime hospital educational meetings allowed GPs and hospital colleagues to learn together.

Many clinical problems were often solved by a quick telephone call to a colleague for advice rather than a referral letter.

I have been a GP partner in Irvinestown now for 15 years and have witnessed a lot of change in that time.

With the retirement of GPs and an inability to recruit younger GPs, maintaining continuity of care is being tested by the demise of smaller single-handed practices, practice mergers into large ‘super-practices’, and the necessary use of alternative ‘rescue’ contract holders.

Out of 17 GP Federations in Northern Ireland, seven areas have greatly benefitted from expansion of the Primary Care Multidisciplinary team (MDT) to include First Contact Physiotherapists, Social Workers and Mental Health practitioners.

It is disappointing, however, that further roll-out has stalled, creating an inequitable divide between practices with and without MDT support.

GP Federations have been instrumental in Primary Care workforce development.

GP pharmacists are now firmly embedded in all practices and are making a huge contribution to improving the efficiency, quality and safety of prescribing.

Many practices have also taken on the training of additional practice nurses and Advanced Nurse Practitioners(ANP).

I am a GP trainer and within my practice we currently have two GP trainees, an ANP trainee and two Year Three University of Ulster medical students attached.

Despite the workload and workforce pressures, rural GPs are prioritising educational activities as they recognise the benefits of improved team morale, and that it is essential to sustaining the primary care workforce.

I am fortunate over the years to have maintained close links with my secondary care colleagues in the South West Acute Hospital.

Gone are the days that we have time to travel into Enniskillen for lunchtime meetings, but once a month we do make a commitment to get together virtually via the ‘Mind the Gap’ Project ECHO network.

I co-chair this online Zoom meeting with Professor Max Watson, and network participants across the primary-secondary care interface co-design an educational curriculum every year, sharing through case-based learning and providing peer to peer support and encouragement.

Through the Covid-19 pandemic, this network moved to weekly meetings and became a lifeline for us all.

Covid-19 indeed triggered a lot of change within primary care, in that most patient contacts are now triaged on a daily basis, with queries then more appropriately navigated to a range of healthcare professionals and admin staff.

The role of the GP therefore has adapted to a more supervisory and leadership role mentoring colleagues, trainees and students.

Another consequence of this filtering of demand is that the complexity of the GP caseload has increased.

We are seeing frailer patients with multiple comorbidities in conjunction with polypharmacy, complex social problems and end-of-life care.

To reflect the fact that GPs are working at the top of their game, some have advocated for a re-branding to ‘Primary Care Consultant’.

With so many other specialities becoming so sub-specialised, I wonder if this could re-invigorate General Practice as the truly holistic speciality it is, and encourage more new doctors to enter GP training?

Irvinestown – the town in which I both live and practice – is a small town on the border of Fermanagh and Tyrone.

Despite being an area of deprivation, it has a very strong community ethos, and we are fortunate to have the ARC Healthy Living Centre embedded at its core.

Not long after moving home I was invited to sit on the Board of this community organisation.

I admit I was naïve about what this would entail. I had read about Michael Marmot and his teachings on social determinants of health, but didn’t realise how formative this journey would be.

Working at the grassroots community level gave me a true grasp of health inequalities and population needs assessment, and spurred me to take up roles on the Local Commissioning Group and later Integrated Care Partnerships.

Through the ARC, I saw how problems such as addiction, post-natal mental health issues and food poverty were translated into local solutions of outreach clinics, Surestart programme, and food banks, to name just a few.

Early exposure to such community organisations at student and GP trainee level has the potential to embed and normalise social prescribing into the consultation.

We are constantly hearing about cuts to the health budget, but forget that so much of the activities that contributes to good health and wellbeing are provided by our colleagues in the community and voluntary sector, and widespread cross-departmental budget cuts are having severe impact here too, particularly with regard to early intervention and preventative activities.

I welcome the tentative steps that are being taken currently to move towards an Integrated Care System for Northern Ireland.

This will bring together a range of partners to take collective responsibility for planning health and social care services with the aim of improving health and wellbeing, and reducing health inequalities.

There is no doubt that in the current financial and political environment, this will be a challenging task, but I look forward with enthusiasm to see the outworkings of this new way of working.

Ten years from now, I envisage that Primary Care will look somewhat different.

We may have to accept that there may not be a GP practice in every small village or town, but the service we receive will be of high quality, outcome-focused, delivered by a team of motivated multidisciplinary professionals and led by GPs (or Primary Care Consultants).

There will be better integration of care with our community and voluntary partners.

With more medical students having spent a greater proportion of their training in primary care, there will be a greater research focus, and a blurring of the primary/secondary care interface aided by joint multi-morbidity outreach clinics.

This supportive learning environment will nurture trainees of all disciplines while providing care for our complex ageing population.

Dr. Laura McDonnell has been a GP partner in Irvinestown Health Centre for 16 years. She has been a board member of the South West GP Federation since October, 2022, and is Treasurer within the federation. She also represents the Federation on the SWAH Strategic Development Group, and on a voluntary basis is the Vice-Chair of the ARC Healthy living Centre in Irvinestown.