A day in the life of a Northern Ireland GP
Official statistics have revealed that 23 GP practices in Northern Ireland have closed their doors since 2014. At the same time, the number of patients at each practice has increased by 11%. With an increasing number of doctors leaving the profession, general practice here is plunging deeper into crisis. One GP tells Lisa Smyth what life is like at the coalface
GP Dr Frances O'Hagan is a senior partner at Friary Surgery in Armagh, as well as deputy chair of the British Medical Association's GP committee in Northern Ireland. She is married to estate agent Art O'Hagan. The couple have three children, Eoin (26), Maeve (23) and Shane (20). This is her diary of one day in the surgery.
7.45am: Arrive at the surgery and get settled in for the day. It's a Monday morning, so I checked the system last night to see who used the GP out-of-hours service and who was admitted to hospital over the weekend. I like to give myself a bit of a head start on the day, because there's so much to get through.
7.50am: Start working through some of the paperwork that needs to be done. Our practice has operated a total triage system for three or four years now, which means that any patient can ring in about anything and ask to be seen that same day. The phone lines open at 8.30am, so if I don't come in and get started on paperwork before then, I won't get another chance through the morning.
8.30am: The first patients start ringing in and the doctors triage those calls, depending on the information the person has given to the receptionist. We ring back the patients, according to clinical need, so we contact the people with the most urgent medical problems first.
The first person I speak to is a young man who thinks he might have a chest infection. He has been a patient with the practice all his life, so I know he also has asthma, so I arrange for him to come in and see me later in the morning. That's one of the things I like about general practice - the continuity of care. I've been here for so long that I know most of my patients and if I don't know them, I know their family and their family history.
The next patient I speak to has told the receptionist that they're having problems with low mood. When I ring them back, I can tell they are a bit more complex and I'm going to have to take a bit longer with them, so I put them down for a 15-minute slot later in the morning. Dealing with a patient with a mental health problem isn't something that can be done in five minutes.
We've also had a call from a mother this morning, whose four-month-old baby has been unwell overnight. She would like someone to take a look, so I give her a ring to find out a bit more and we arrange for her to come in in the afternoon, because she can't make it this morning.
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The next person I speak to has an ingrown toenail that they need me to take a look at, so I make an appointment for them. Another call I make is to speak to a woman who wants to speak to me about recurrent urinary tract infections.
I've also spoken to several people who didn't need to come in, as I was able to give them advice over the phone and I've spoken to my district nurse and palliative care nurse about a complex terminal care patient.
Our patient clinic starts at 10am and, by the time that comes around, I haven't lifted my head from I arrived in the surgery - I've rang back 20 patients and made same-day appointments for 12 of them.
This is only the start, as patients are added to the triage list all day. So, while I stop ringing patients to see the appointments, the list will grow with problems that need to be seen urgently and I have to constantly revisit the list between appointments to see who else needs seen and make sure that an urgent problem is identified and seen to quickly.
10.05am: The first patient I see today is the young man with asthma. He was supposed to be here for 10am and he's five minutes late, so that sets me back for the start of the appointments. I examine him and diagnose a chest infection.
10.15am: The next patient in is the one who has the ingrown toenail. After I've examined the toe, the patient begins to ask me for some advice about another problem - this kind of thing happens fairly often.
The total triage system means that we can make better use of our time by prioritising the patients we need to see most and allocating adequate time to see them. But you can't legislate for the people who ask you to look at something else while they're in with you for a different problem.
He tells me that he's had a sore finger for six months. I do deal with this today, but remind him that if he had told me at triage that I would have given him enough time for all the problems to be dealt with today, as the clinic is already running late.
10.25am: I have allocated 15 minutes to this patient, as they are the one who I suspect has depression. But it actually takes a lot longer, as it turns out they have quite a complex history. This means the clinic is running even further behind.
11am: Fortunately, the next four patients I see are complaining of sore throats and coughs and colds and I'm able to deal with them quite quickly, which helps me to gain back some ground.
11.20am: The next patient I see is the lady who has been having problems with urinary tract infections and it turns out to be more complex and may have a surgical element to the problem. We have a chat and I decide the best course of action is to refer her to see a specialist, but I have to warn her that it could be two years before she is seen.
This is something I've started doing quite recently, because waiting times for hospital appointments are getting so bad. It's across the board, not just in urology and surgery; it's in every specialty.
Just as she gets up to leave, she mentions that she noticed a lump in her breast a few weeks ago. This isn't like the case earlier, where the patient wanted me to check out their sore finger that might have waited to another appointment - it's not something where you can ask a patient to come back another day, so I examine her and agree that it's something that needs to be checked out further, so I tell her I will refer her to the breast clinic.
11.50am: The clinic is running late again, so I'm under a bit of pressure to make up time. Fortunately, the next two patients are complaining of more minor problems and I am able to see them quite quickly.
12.05pm: The next patient is someone who is waiting for gall bladder surgery, but they have been waiting for quite a while and they are in quite a bit of pain.
We have a chat about the different ways we can try and manage the pain until they get their operation and I tell them I will chase up to find out when the operation might happen. This is becoming increasingly common in the job - we have patients who need treatment for painful and debilitating conditions who actually decide to bypass the NHS and go private. It's terribly frustrating as a GP, because you just want to help your patients.
12.20pm: The next patient is here because they're having problems with their mental health. They're also addicted to heroin, which was never a problem before, but is now becoming an issue in Armagh, just like it is in the rest of Northern Ireland.
Fortunately, I am aware of their complex history, so I have allocated plenty of time to see them and I hadn't arranged to see anyone else after them during the morning session.
12.55pm: I manage to get finished up five minutes before the end of the session, so I start writing up the referral letters from the patients I saw during the morning.
1pm: As a practice, we like to have a meeting once a day, even if it's only for five minutes, where we can discuss patients we have seen. It's so busy today that the practice manager has been out and brought in some sandwiches for us to eat during the meeting before house calls.
1.10pm: Today, I am going out to see a lady who has COPD. She has been having problems with her breathing overnight and her husband is concerned she might have a chest infection. She isn't well enough to come into the surgery for me to look at her, but we need to get out and see her in case she has an infection and needs an antibiotic.
2.05pm: I get back to the surgery and have some time to go through more paperwork that has come in through the morning. There is a letter from a consultant, who saw one of my patients for one problem and mentioned there was something else they were worried about. I give them a ring and let them know that they need to come in for some blood tests.
I also get a chance to look at some blood test results and some other letters that have come back. Some are just for information and some are asking me to do things.
2.30pm: Afternoon clinic starts and the first patient I see is the new mum with the baby who has been unsettled overnight. I examine the baby and diagnose reflux. While I am talking to the mum, I realise that she is struggling with her mood, so we have a bit of a chat about that.
It takes a while to get her to open up, but I diagnose her with postnatal depression and then we spend some time discussing what we can do to help her. I also ring her health visitor after she leaves to arrange for her to follow up in the next day or two.
3.10pm: The last appointment took longer than expected. The next patient is a man who is waiting for a hip replacement.
He wants to come and see me and discuss what he should do, because he's in so much pain he's thinking he may have to take early retirement.
Unfortunately, there's very little I can do other than chase it up with the hospital and the patient decides he is going to have the procedure done privately.
3.20pm: The next patient I see is someone who has been having migraines. It's fairly straightforward, so I'm able to deal with them quite quickly.
3.25pm: The next patient is a woman who has been having irregular bleeding and some other symptoms that mean I want to do an examination. I decide to make a "red flag" referral, which means she should be seen quite quickly.
I then get an emergency call from the staff in the treatment room, where an elderly lady has collapsed while they were taking blood. I leave to assess her and, thankfully, it is a simple faint.
3.45pm: The rest of the afternoon is spent seeing patients with fairly minor issues, but I still don't get the list finished until almost 6pm.
5.55pm: I start on more paperwork, chasing up blood test results and going through letters.
6.40pm: I leave the surgery so I can call with my palliative patient on the way home and follow up with him and the family after several contacts today by our excellent district nursing and palliative care team.
I try to get home for 7pm to make the dinner and, after we've eaten, I can log back on to the computer and finish off the paperwork I didn't get through during the day.
It's another day that I did not notice fly by, but I have to say that I love doing this job every day and I feel privileged to walk with my patients through the good and bad times in their lives.
Being a GP is hard work, it has changed so much from when I started out, but it's a job I love. We literally see people from the cradle to the grave and we build up such a relationship of trust. Confidentiality is absolutely paramount, it's absolutely guaranteed and at the forefront.
People allow us to share their journey and I consider it such a privilege - something that you don't get in any other job.