The key to equitable access to health services for rural populations is well-trained, skilled and motivated healthcare workers, according to Prof. Liam Glynn, a general practitioner (GP) in Ballyvaughan, Co. Clare, and Prof. of General Practice at the School of Medicine, University of Limerick (UL).

His comments come as the Irish College of General Practitioners (ICGP) reiterated its call for a Working Group on Future General Practice to plan for serious GP workforce pressures, in a submission to the Oireachtas Joint Committee on Health.

It is estimated that Ireland needs over 2,000 GPs over the next decade, to meet impending retirements and population growth. Over 700 GPs are due to retire in the coming decade.

Dr. Diarmuid Quinlan, medical director of the ICGP said that Ireland has 29% fewer GPs per head than the UK, and existing GPs are seeing increased workload and demand.

“The college has steadily increased its training numbers, and we aim to train 350/year by 2026. But at present, innovative solutions are needed to address these workforce problems and in particular, the retention of GPs when qualified,” he said.

“We saw during the Covid-19 pandemic how central and significant the role of general practice is in Irish healthcare. Now is the time for GPs to be central to the plan for future healthcare delivery,” said Dr. Quinlan.

Delivery of healthcare in rural Ireland

Prof. Glynn said it is vital to think of the challenges of delivery of healthcare in rural Ireland and chief among those is the recruitment and retention of a healthcare workforce.

“Securing equitable access to health services for rural populations continues to be a challenge for governments and policymakers around the world. At the core of this complex challenge is a global shortage of well-trained, skilled, motivated healthcare workers,” Prof. Glynn said.

“The practice I work in employs seven staff directly and two indirectly in a village with a census population of 250.

“So practices are valuable economic units and investment in a transformed healthcare workforce has the potential to create the conditions for inclusive economic growth and job creation, thereby promoting greater economic stability and security, itself a key factor in better health outcomes – so thus, a virtuous circle is created,” Prof. Glynn said.

“Such investment can play a transformative role in expanding and financing decent work opportunities. Equally, the removal of such a workforce has a disproportionately negative effect on small communities demonstrating the truth of the axiom ‘no doctor, no village‘.

Rural communities have been served very successfully in this country by often small GP-led primary care teams, which research demonstrates can deliver both cost-effective and high quality care to these populations, according to Prof. Glynn.

“The continuity of care created by such a system is associated with reduced need for out-of-hours services, reduced acute hospital admissions, reduced emergency department attendance and is also associated with decreased mortality,” he said.

“However, like other developed countries globally, Ireland has a rural healthcare manpower crisis which is likely to worsen significantly in the next five years with a large number of the current GP cohort in the Republic of Ireland set to retire according to recent figures.

“As a result, an increasing number of rural GP posts remain unfilled, with lists being dispersed or ad hoc and expensive locum arrangements in place with a significant erosion of that principle of continuity of care on which rural healthcare delivery has been traditionally based,” Prof. Glynn said.

“The ‘corporate knowledge’, to use a business phrase, of individual and family health profiles that each of these multi-disciplinary, community-based healthcare teams possess in relation to the population they serve and the therapeutic relationships on which these are based, are an enormous health asset in our healthcare system which we should make every effort to maintain, sustain and develop,” he contended.

“Once these are lost, they are lost forever, and their ability to reduce the need for out- of-hours services, acute hospital admission and emergency department attendance is also lost.”

The World Health Organsiation (WHO) guideline on health workforce development in rural and remote areas provides an excellent evidence-based blueprint, according to the Clare GP.

Developing a rural-centric workforce

“We need targeted admission policies to enrol students with a rural background in health worker education programmes,” Prof. Glynn continued.

“We need to connect and embed health education institutions closer to rural communities and ensure they are community facing and have a curriculum which is dominated by community-based teaching programmes.

“We need to expose healthcare students to rural and remote communities and rural clinical practices and rural health topics throughout the educational continuum.

“We need to design and facilitate access to continuing education and professional development programmes that meet the needs of rural health workers to support their retention in rural areas,” he said.

“We need to develop different types of health workers for rural practice, such as expanded paramedic roles and advanced nurse practitioner roles to meet the needs of communities based on people-centered service delivery models, including enhanced scopes of practice.

“We need to employ a package of fiscally sustainable, financial and non-financial incentives for health workers practising in rural and remote areas. The rural practice allowance is one such key support in this State, but access to it needs to be widened and it needs to be increased,” the Clare GP said.

There is a need to switch the current focus on large urban-based healthcare infrastructure development and invest in rural healthcare infrastructure to ensure decent working conditions for rural health workers, he contended.

“We need to develop a policy of career development and advancement programmes and career pathways for health workers, including the opportunity for fellowships, bursaries or other education subsidies and the development of networks and associations and other social recognition measures,” said Prof. Glynn.

“Sláintecare is predicated on having a health service with a foundation in primary care where the right care, is delivered to the right patient, in the right place, at the right time.

“This is a very sensible and also evidence-based founding principle, as we know that over 90% of healthcare contacts happen in the community and any healthcare system that has primary care as its foundation is more cost-effective, and delivers better health outcomes for people,” Prof. Glynn said.

“However, this will not be achieved without a healthcare workforce in our urban centres, but more critically outside our urban centres where they are most under threat.

“There is a blueprint to achieve this but this has to be resourced and implemented before more of this vital healthcare infrastructure is lost,” he concluded.