Summary of key results
In this study, we estimated the number of consultations that occur in general practice in Ireland. With a sample of 507 practices, 34,594 GP consultations and 13,161 PN consultations, we extrapolated these figures to estimate that 21.4 million GP consultations and 7.7 million PN consultations occur annually. By using the 2019 Irish population figure of 4.9 million [14], we estimate that people visit a GP 4.34 times a year. Using the same calculation for the population, the figure increases to 5.91 general practice visits per person per year when both GP and PN visits are included.
We found differences in the average number of consultations per GP carried out at single-handed practices compared to group practices. Single-handed GPs had an average consultation rate of 32 per day compared to 29 per day for GPs in group practices; this difference was found to be statistically significant (p < 0.05).
In our sample, only 5.8% of practices did not employ a PN on at least a part-time basis. PNs completed an average of 26 consultations a day and conducted over a quarter (27.6%) of all consultations. Overall, 17.4% of nurse consultations were conducted via telemedicine compared to only 10.0% for GPs.
Comparison to the literature
Between 2015 and 2019, the proportion of single-handed GP practices in Ireland varies from 18 to 25% [5, 11], which is consistent with the 18% found in our responding sample.
In 2015 and 2019, around 82% of practices were found to employ a practice nurse on at least a part-time basis [5, 13], which is comparable to our findings.
Our estimate of annual GP consultation rates in Ireland sits between other estimates from 2013 to 2019. The Department of Health’s health capacity report estimated 18.9 million GP consultations in 2016 could rise to 26.2 million in 2031 and PN consultations could go from 6.8 million in 2016 to 9.5 million in 2031 [13]. The 2019 ESRI estimate was 17.5 million GP consultations [5] and Behan et al.’s 2013 estimate (which includes out of hours consultations) was 24.6 million [15]. While all three are similar, the lack of nationally available data about general practice activity means that it is hard to have an accurate count of consultations and data are not directly comparable. In the Department of Health report, a purposively designed demand and capacity model was employed making use of data from over seven sources including CSO and HSE data [13]. The ESRI estimates [5, 16] are based on amalgamating various sources regarding GP supply, patient usage and CSO statistics. Behan et al. [15] includes out of hours consultations and covers one full year of data collected retrospectively at one point in time from six practices.
The Organisation for Economic Co-operation and Development (OECD) reported an average of 5.0 annual consultations per person in 2018 [9] which equates to 24.1 million annual consultations. Eurostat reported the same amount [10]. Most recently, the 2019 Healthy Ireland Survey [17] found that the average person saw their GP 4.5 times in a year, which is very close to our estimate of 4.34 visits per annum based on the number of consultations reported by GPs. However, all but two of these estimates used different methods to determine the consultation rates.
GPs told us they work an average of 9.7 h daily, which is consistent with other Irish findings [6, 17, 18]. This includes admin time, shown elsewhere to be an average of three hours per day [6, 18]. We estimated GPs spend an average of 13.7 min on a consultation, which is slightly lower but in line with findings of 14–15 min by others [18, 19].
Contribution/implications for policy and research
It is important to understand health care utilisation for future health planning; accurate and routine data collection and trend analysis is essential to this understanding. From the data presented in this paper, it is clear that practice nurses have an important role to play in Irish general practice.
Usage of telemedicine is greater among practice nurses and therefore its use in Irish general practice pre-COVID-19 suggests it may be linked to the reason for consultation. According to the Irish Practice Nurse Association, PNs carry out a wide range of services which include nutrition management, smoking cessation, preventative care and self-management support [20]. Telemedicine delivery of many of these services has been found to have equivalent outcomes to face-to-face appointments [21]. As these services are included under the practice nurse’s scope in Ireland, this could be why they had a higher proportion of consultations using telemedicine.
Using the most recent European figures [9, 10], there was an increase in visits to doctors in 2015–2016, which could be related to the introduction of free GP services for those aged under six and over 70 years. However, this drops again by 2018 despite a growing population. All of these estimates are much higher than the 3.2 consultations per person reported by CSO in 2010 [15], again highlighting the need for a national data collection strategy to capture all consultations in general practice. Without this, accurate workforce predictions and planning will be very difficult.
Part of Irish national health policy [12] is an emphasis on better collection and use of data to inform decision-making and employ population-focused health planning. As shown by our results, standard, centralised methods and collection schedules need to be implemented for Irish general practice to accurately gauge staffing requirements. In 2018, the OECD reported that Ireland has one of the lowest levels of doctors per capita in Europe, at 2.9 per 1000 citizens [22] - 24% of these doctors are GPs. Comparatively, Greece has the highest at 6.6 per 1000 people, and the European average is 3.6 per 1000 people. This suggests that Ireland requires more doctors, especially when factoring in international and national healthcare targets [2, 5, 6, 12, 13, 18]. To meet current demands and achieve goals outlined by the Irish national healthcare policy “Sláintecare” [12] and the UN Sustainable Development goals to ensure affordable, universally accessible healthcare for everyone [23], more clinical staff is a requirement for the evolving health system.
In 2019, the ICGP provided evidence that GPs cite working conditions with high numbers of clinical consultations and administrative duties as reasons for moving abroad [24]. Both that report and the investigation by the ESRI [5] found that there could be a significant shortfall of GPs in Ireland in the near future. Compared to the UK and other European countries, more Irish GPs experience emotional exhaustion, a contributing factor to burnout [25]. One solution proposed is increased training of PNs, which would enable them to conduct more complex consultations, thereby increasing capacity in general practice. This supports the Department of Health recommendation to increase the number of FTE PNs by 40–89% [13] depending on system reforms.
General practice and how the public uses health services have been forced to change dramatically because of the COVID-19 emergency. There has been an increased need for remote consultations to reduce the spread of the highly contagious viral infection, which could provide a lasting solution to increase capacity in general practice [26]. Further to that, streamlined use of technology could reduce time spent on administrative duties. This unique situation has presented us with an opportunity to look at how practices might deliver care differently. However, the feasibility, acceptability and impact of all these possible solutions need to be assessed.
The ICGP is currently repeating this survey in order to quantify the changes in consultation rates and delivery method during the pandemic and once the pandemic passes, plan to replicate it at different time-points during the year. Moving forward, better mechanisms for national data collection on general practice activity and workload are critical to future-proofing primary care in Ireland especially as new technology emerges.
Strengths and limitations
This survey had some limitations, as the sample was self-selecting and we did not capture information about patients. This means we were unable to comment on consultation rates by demographics and can only provide estimates of total consultations. Furthermore, appointments conducted in the out of hours setting were not captured, and hence our results underestimate the total workload of GPs. Data was received for each day of the normal working week, although there was a higher volume received for Monday. Another limitation is that the survey was conducted during the winter which has been shown to increase rates of respiratory illnesses and healthcare usage [27]. These factors may have resulted in an overestimation of total annual consultations. However, we did collect information from more than 500 practices spread across the country and in varying locations and estimate that this data represents 32% of all practices.
