The people of the offshore islands of Ireland, healthcare professionals and patients alike, are no strangers to using all technology available at the time to access care. From lighting a bale of hay to signal the need for help from the mainland to dropping medications by drone a hundred years later, many advances have been made. My father, GP to the islands for over 40 years, recounts visits where he travelled on foot or bicycle to see patients and I know there was one incident involving a GP seated in an armchair in a trailer being towed behind a tractor. Now there are engines instead of oars and cars instead of bikes.
As technology has become more advanced, we have embraced it all on the islands. Phones, faxes, emails, computers, and smartphones have all been integrated into use for healthcare. Technology is used to help care for patients every day of the week. This latest home health project is a wonderful new platform for improving access to healthcare and we are eager to see it continue and expand beyond the timeline of this pilot project. In the short time since the project started, several new diagnoses have been made that most likely would have been delayed without the project and the management of known conditions has improved. Patients are being given the knowledge and tools to become more mindful of their health and in many cases to start to self-manage their chronic conditions. They are being empowered to improve their health and this will lead to an ability to stay healthier for longer and therefore to remain independently on the island for longer. Work continues on making more consultations with secondary care and the allied health professionals available electronically as well so that unnecessary travel can be eliminated. This patient-centred model should be rolled out to non-Island as well as island communities. Improved connectivity will benefit all walks of life on the island and encourage more people to stay.
A detailed review of all of Ireland’s inhabited islands was carried out between 2014 and 2016 by the HSE and published in 2017. Among the many recommendations , the report states that:
The HSE will work to develop telemedicine services for islands with a view to facilitating the delivery of video link consultations; providing services that promote mobile assessment and enhanced service delivery on islands in line with best practice; mproving multidisciplinary working; and providing online training and education
However, all the technology is reliant on healthcare professionals, especially the GPs, to function. The Government's own National Islands Policy 2023 – 2033, refers to the HSE Primary Care Island Services Review and supports the need to provide the right care in the right place at the right time. GPs form the foundation of the healthcare service in Ireland. To make a simplistic comparison, if healthcare is compared to a house then GPs are the foundation. Of course, we need walls and a roof and these can be compared to secondary and tertiary care in hospitals. The allied health services are also needed to fit and furnish the house. However, we cannot build an extension without having more foundations, and no matter how many extra rooms are created or how many fancy fixtures and fittings we install, if we do not have a solid, adequate foundation cracks will appear and the house will eventually collapse.
In the recent Irish College of General Practitioners, ICGP publication, Shaping the Future, it was noted that Ireland has one of the highest rural populations in Europe at 31%. However, only 15% of Irish GPs cater for this highly dispersed and often elderly population with many complex health needs. Therein lies a significant inequity of access to healthcare for our rural and island populations. Over 29 million consultations take place in general practice each year and each patient, on average, visits his or her GP 4.3 times per year. Almost a quarter of these GPs are aged over 60.
I commenced work as a GP in Mayo in September 2001. Over the past 22 years the population of the county has increased by approximately 20,000. The age profile has also gone up. As per the Central Statistics Office, CSO, data Mayo has one of the highest average age profiles and one of the highest old age dependency rates in the country. People are living longer and have more complex care needs. The variety of treatment options available has risen and the workload for all healthcare professionals has gone up. Given the ever-increasing number of medical cards, the development and expansion of the chronic disease management, CDM, programme and the significant work that the Covid vaccination programme has brought, to mention a few, the workload for GPs continues to rise all the time. This is hugely important work in terms of the benefit for individuals, families, and their communities but there are fewer and fewer GPs available to do it. In September 2001, there were 78 General Medical Services, GMS, GP posts in County Mayo. At the same time, there were 21 consultant posts in the county hospital, now Mayo University Hospital. In the intervening 22 years the number of consultant posts has nearly tripled to 57 but the number of GMS GP posts has not changed and remains at 78. There are many other GPs working in the county. There are part-time and sessional GPs, but the overall number has not increased significantly, and the GMS posts have stayed the same, with some of these not even being filled. There are five GMS posts in the county that remain empty today and four of these are rural. The fact that the GMS contract still contains a 24/7/365 commitment to patients is certainly a huge factor in younger GPs voting with their feet and not taking up GMS GP posts. Another recommendation in the HSE's island services report is that GPs be provided with adequate locum supports to enable them to take leave and to attend ongoing training on a consistent basis.
Unless the conditions improve dramatically for GPs, in particular rural and remote GPs, this country will continue to lose our highly trained and talented GPs to countries with better working conditions. Without a GP to look after the healthcare needs of an island community, the population will slowly decline. The No Doctor, No Village campaign of 2016 is even more true for a community on an offshore island. What is required to turn this around? The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick last year, with more than 650 participants coming from 40 countries and an additional 1,600 engaging online, carefully considered this question and in response published the
Limerick Declaration on Rural Healthcare which asserts the right of rural and Island communities to equitable access to healthcare and is a blueprint to transform healthcare for rural and Island communities on this island. This declaration is also in support of World Health Assembly resolution 72.2 on primary healthcare which calls on all stakeholders to provide support to member states in mobilising human, technological, financial and information resources to help build strong and sustainable primary healthcare, as envisaged in the Declaration of Astana.
The Limerick Declaration on Rural Healthcare calls for a number of key actions for rural and island communities. It argues that the current focus on large urban based healthcare infrastructure development should be widened to include investment in rural healthcare infrastructure so as to ensure decent working conditions for rural healthcare workers. This will include funding to cover investment in innovative technological solutions to enhance, but not replace, the face-to-face service. The declaration also asserts that socially accountable higher educational institutions need to develop rural academic educational and research infrastructure closely aligned to the communities they serve and that building on established international examples, specific undergraduate medical, nursing and allied health programmes should be developed which are dedicated to producing graduates who have the skills, attitudes and desire to work in rural and remote locations. In that context, we need targeted admission policies to enrol students with a rural background in health worker education programmes. Specific rural curricula and pathways should exist within undergraduate and postgraduate training where exposure to rural practice should be maximised based on the 'If they can’t see it, they can’t be it' principle. We also need to deploy a package of fiscally sustainable financial and non-financial incentives for health workers practising in rural and remote areas. Here in Ireland, we have the rural support framework for general practice but the criteria for access to this are very narrow and the quantum is relatively very small. Both need to be increased immediately, not in 2024 when the framework is up for review. The challenges facing smaller rural healthcare practices should be recognised and supported through innovative solutions involving co-operatives to deliver equitable out-of-hours commitments, shared appointments, salaried posts, fellowship positions and partnerships and clusters of practices. We need guaranteed holiday, maternity, and parental leave and this should be a minimum requirement for a rural healthcare practice.
On the development of a clear rural GP career pathway or pipeline, a target regarding the proportion of Irish medical graduates required in general practice to deliver Sláintecare should be set. The equivalent figure in the UK is 50%. To keep an eye to clinical, academic and advocacy leadership for the above, chairs of rural general practice should be funded within higher education institutions, with an additional national clinical lead for rural healthcare within the Irish College of General Practitioners and a national lead for rural healthcare deliver within the HSE. We must enable dynamic co-production of data on rural health between communities, health workers, academic researchers, policymakers and civil society organisations by mainstreaming rural research activities. The lived experiences and voices of the community need to be reflected in the research used to generate this evidence. Ring-fenced and proportional research funding that is accessible to communities and rural researchers, building an equitable community of research practice, is required to deliver this. The recent motion from the Rural, Island and Dispensing Doctors of Ireland group at the Irish Medical Organisation AGM of a 2-for-1 model of practice needs serious consideration.
Equitable access to healthcare is a crucial marker of democracy. Hence, I call not only on the Irish Government, but on all governments, policymakers, academic institutions and communities globally, to commit to providing their rural and island dwellers with equitable access to healthcare that is properly resourced and fundamentally patient-centred in its design. Otherwise, it is very clear the rural and island communities will again be left behind. All the technology in the world will amount to little if there are no GPs to run the services.