General practitioner workforce planning: assessment of four policy directions.

BACKGROUND: Estimating the supply of GPs into the future is important in forecasting shortages. The lengthy training process for medicine means that adjusting supply to meet demand in a timely fashion is problematic. This study uses Ireland as a case study to determine the future demand and supply of GPs and to assess the potential impact of several possible interventions to address future shortages. METHODS: Demand was estimated by applying GP visit rates by age and sex to national population projections. Supply was modelled using a range of parameters derived from two national surveys of GPs. A stochastic modelling approach was adopted to determine the probable future supply of GPs. Four policy interventions were tested: increasing vocational training places; recruiting GPs from abroad; incentivising later retirement; increasing nurse substitution to enable practice nurses to deliver more services. RESULTS: Relative to most other European countries, Ireland has few GPs per capita. Ireland has an ageing population and demand is estimated to increase by 19% by 2021. Without intervention, the supply of GPs will be 5.7% less than required in 2021. Increasing training places will enable supply to meet demand but only after 2019. Recruiting GPs from overseas will enable supply to meet demand continuously if the number recruited is approximately 0.8 per cent of the current workforce per annum. Later retirement has only a short-term impact. Nurse substitution can enable supply to meet demand but only if large numbers of practice nurses are recruited and allowed to deliver a wide range of GP services. CONCLUSIONS: A significant shortfall in GP supply is predicted for Ireland unless recruitment is increased. The shortfall will have numerous knock-on effects including price increases, longer waiting lists and an increased burden on hospitals. Increasing training places will not provide an adequate response to future shortages. Foreign recruitment has ethical considerations but may provide a rapid and effective response. Increased nurse substitution appears to offer the best long-term prospects of addressing GP shortages and presents the opportunity to reshape general practice to meet the demands of the future.

Impact of a GP cooperative on lower acuity emergency department attendances.

BACKGROUND: In 1998 'Dubdoc', Ireland's first out-of-hours general practice emergency service, opened in an outpatient suite in St James's Hospital with a separate entrance 300 m from the emergency department (ED). Dubdoc was established with the aim of providing an easy access out-of-hours service for ambulatory patients of those doctors supplying the service. AIM: To determine whether ED attendances for patients in the lower acuity triage categories 4 and 5 have changed since the establishment of 'Dubdoc'. METHODS: A retrospective review of all attendances at the 'Dubdoc' service was compared with attendances at the ED for triage categories 4 and 5 of the same hospital over a 9-year period (1999-2007 inclusive) for equivalent times of day. RESULTS: ED attendances during 'Dubdoc' hours have decreased as a proportion of all attendances for triage categories 4 and 5. ED attendances for triage categories 4 and 5 fell substantially during the study period. CONCLUSIONS: Although the presence of the 'Dubdoc' service has resulted in a decrease in ED attendances for triage categories 4 and 5, this is a minor proportion of the overall decrease in attendances in this group of patients.

Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care.

BACKGROUND: Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument. METHODS: A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status. RESULTS: Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation. CONCLUSION: Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words).