Introduction by Croakey: The sign above Irish GP Dr Edel McGuinty’s desk reads “FIXER OF EVERYTHING”, as pictured above.
As part of his Churchill Fellowship investigating how general practitioners provide care at the Deep End, working to address systemic health inequities in socioeconomically disadvantaged communities, Dr Tim Senior has enjoyed the rare opportunity to sit in on consultations in Dublin – including with McGuinty.
Below Senior shares some observations, reflections and lessons from the other side of the consultation door, finding that “curiosity, compassion and stubbornness” are common traits amongst Deep End GPs.
Tim Senior writes:
A patient once told Dr Edel McGuinty, an experienced GP at Riverside Medical Centre, in Mulhuddart, a deprived suburb in the north-west of Dublin, that she is “the feckin’ shite doctor”.
The patient didn’t mean it in a bad way, telling McGuinty that she went to see other GPs for trivial things, but when she had “a load of feckin’ shite to deal with” she took it to McGuinty.
It’s a common theme, among all the Deep End GPs I’ve met, this ability to be the doctor people choose to see for their multiple needs, for complex comorbidity, for mental health arising from social circumstances and for advocacy letters and form filling.
I’ve had a very rare opportunity on this trip to go in behind the closed door and see different GPs working with a range of patients.
Most people have only ever seen a GP at work when they’ve been a patient. Medical students probably have the most opportunity to see a range of GPs working with a range of patients.
So this opportunity I’ve had, to see experienced GPs work with their patients at the Deep End, has been rare and inspiring.
In Dublin, I saw McGuinty navigate questions of alcohol consumption. “I’m not your grandma, you’re not in trouble!” she tells the patient.
Also in Dublin, I’ve had a long conversation with Dr Anna Brueg about her approach with her patients using Conversations Inviting Change, a narrative medicine approach to professional consultations with patients way beyond a paternalistic biomedical approach.
I’ve also seen Dr Brid Shanahan consult with an interpreter in Albanian for a Roma patient, at the same time, skilfully making them feel at ease.
Stories beyond the data
Everywhere I look, every GP I meet is doing these judgements in action, about what the patient wants and needs, what is on our agenda, what is achievable now, what are the patient circumstances and local resources we can call on, what the direction might be over the next six consultations, how can we build and maintain trust and rapport, as well as what chaos might be happening in the waiting room.
To an observer of the recorded data, or anyone outside the consultation room, very little of this is apparent.
The health system in Ireland, like that in Australia and in England, is built on averages. It imagines the needs of an average person, with an average number of consultations, and funds accordingly. There’s extra for older people, because of the extra health needs for older people.
“But my patients don’t reach that age,” says Dr Brid Shanahan (echoed by all the other GPs I spoke to). “We never get that funding.”
The experience of all the GPs I’ve met – backed up by research – is that multimorbidity occurs at least 10-15 years younger in the worse off compared to the better off. (The Irish health system is not alone in this. The Australian system doesn’t look at deprivation for funding, and I have also discovered that the same happens in England.)
Ireland’s health system is quite similar to Australia’s, in that people pay a fee to see the doctor. If they have a medical card, which is means tested, they can see the GP for free, as well as have reduced cost prescriptions.
For patients with a medical card, the GP is paid a sum for looking after them for the whole year – this is the fee that has an age rating, but not a deprivation rating.
Clearly, people with multimorbidity need longer consultations, and often need to be seen more often, so this funding mechanism systematically underfunds general practice in deprived areas.
Most of the GPs I met were working in traditional partnership models of general practice, and struggled with the underfunding in this system.
Shanahan works in a different model, though. She works in a practice run by GPCareforAll, a charitable not-for-profit, set up by Dr Austin O’Carroll, a powerhouse of Irish general practice.
There’s no extra funding available from the health system, but the administration and business of running a practice is taken on by the charity, allowing the GP to focus on providing good medical care, and allowing some of the financial benefits of a not for profit.
However, in an echo of the payroll tax issue in Australian states, there’s a potential tax ruling in Ireland designed to prevent corporate takeover of the general practice sector in Ireland that is also preventing GPCareForAll from expanding its footprint. Watch this space!
Personal matters
One of my personal highlights in Dublin was being invited to talk about my experiences in Australia to a group of GPs in training.
The higher rates of younger patients with multiple chronic diseases, along with the prevalence of mental health caused by housing and other social circumstances was familiar to the GPs in training working in deprived areas of Dublin. Also familiar was the causes of the causes – the availability of food, air quality, and having pleasant places to walk – all varying by deprivation across Sydney.
One of the training programs in Dublin explicitly trains in Deep End practices – this program also was set up by O’Carroll – and all the strengths and challenges of working in marginalised communities in Australia were the same as those in Dublin.
In the end, my experience in Dublin has shown how different health systems are able to recreate the same problems from different starting points. Health systems aren’t free of the context of the prevailing political, economic and social contexts.
But neither are the GPs. While GPs have a deep understanding of the ways in which the system fails their patients, and are aware of epidemiology and health data, what they share are stories.
All the GPs understand the specific stories of their patients, and the context in which they happen. Solutions are found in the attention to detail in understanding someone’s story – not just diagnoses, not just medications – but the person, the community and their place.
I ask Dr Edel McGuinty what has kept her going for such a long time.
She tells me that when she first read about the work of the Deep End GPs, she wrote a letter to the BJGP, saying that she felt like a patient with a rare disease who had just found out their diagnosis.
This sense of isolation is common, and the feeling of recognition and camaraderie among the Deep End GPs in Dublin is recognisable.
McGuinty puts the secret of doing general practice in the Deep End down to three things: “Curiosity, compassion and stubbornness”.
These are characteristics I keep on coming across in all those I meet on this Fellowship.
Or, as Dr Edel McGuinty’s patient might say, they are “the feckin’ shite doctors”. In the best sense.
Bookmark this link to follow Dr Tim Senior on his #ChurchillDeepEnd investigations
