The modern practiceThere is a new dynamic emerging in general practice which often works with complementary medicine. Padraig O'Morain outlines one case of GP 'think group'
'I have always known I never wanted to practice single-handed," says Dr James Keely. "I can't counsel everybody. I can't sort out everybody's low cholesterol diet."
About half the Republic's GPs are "single-handed": they work alone, sometimes without secretarial assistance. But under the Government's Primary Care Strategy, this will change. Groups of GPs will work together and co-operate with each other and their practices will include paramedics such as practice nurses, physiotherapists and occupational therapists.
One GP practice has been implementing this sort of vision since before the Primary Care Strategy was written. Seabury Medical Centre in Malahide, Dublin, has three GPs including Dr Keely, and a practice nurse who does baby vaccinations and runs women's health clinics.
Paramedics doing part-time sessions at Seabury include a dietician, a clinical psychologist, a podiatrist/chiropodist, an osteopath, a counsellor, a reflexologist and a physiotherapist. It has three secretarial/administrative staff.
"I am in practice since July 1994 and within a year we were looking for all these people," says Dr Keely. "It just makes sense to take these people on-site and then you have a multidisciplinary service."
For patients, the arrangement means choice, not only in terms of quick and convenient access to paramedics, but also between Dr Keely and his GP colleagues, Dr John Gilbert and Dr Veronica Murphy. "I might see the kids in a family, Dr Murphy might see the mother and Dr Gilbert might see the father," he says.
"Where it comes in handy for us is that you can immediately refer to one of your colleagues for a second opinion," he adds. "Even when you are looking for advice on managing something, a diagnosis or something like a rash it's very easy to knock on the other guy's door and get them to come in and say, what do you think of this?
"In the present climate where people give out about medical fees, we would say we give value for money if you can choose between three different GPs."
Seabury charges €45 for a GP consultation. Patients are free to move between the different GPs, if they wish. This is explained on their first visit, "but people still say, 'you weren't here last night, was it all right that I went to see Dr Gilbert?' I tell them that's what I want them to do."
The fact that a GP can refer a patient to a paramedic in the practice and can - with permission - give some background on the reasons for the referral is "a huge plus for patients", he says. This is especially so in the case of referrals to the clinical psychologist or counsellor.
"They don't have to start from scratch again. They feel you are helping them along with their problem."
Having three GPs also means patients can avoid lengthy spells in the waiting room during the walk-in clinic.
"Between us we often see the same patient on different occasions," says Dr Keely. This means ongoing communication between the GPs about the particular patients "and most patients are happy with that".
There is one limitation: the medical card does not cover patients to see the paramedics. Seabury, he says, provides an excellent example of how GPs and paramedics working together could keep patients out of hospital out-patient clinics and off the waiting lists, but the health boards will not pay for it, he says.
For instance, "there's no GP practice I am aware of where medical card holders can avail of free services from a psychologist".
The expansion of GP services along the lines practised at Seabury will take investment both in facilities, equipment and staff and in covering medical card patients, he believes.
But the difference to patients could be enormous. On a simple level, "we use a courier to send blood tests to the hospital. We don't have to send patients to the hospital for blood tests." This can spare a patient the loss of a day's work to keep a hospital appointment.
And the availability of a whole variety of paramedics in the practice enables patients to get treatment quickly and without investing large amounts of time in trips to out-patient departments or other clinics.
"It's adding a bit of value," declares Dr Keely. "I would be very positive about that."
Clinical psychologist Alison Rooney
It is "relatively unusual" to have a psychologist doing sessions at a GP surgery, says Alison Rooney.
But she believes clients find it helpful to be referred to a psychologist known to a GP with whom they have a good relationship. "When it's someone the GP knows it makes it easier to come along." And seeing her in the surgery is another plus: "Coming into a familiar place is helpful."
"The GPs here are interested in broader interventions than simply prescribing medication although medication can have a very important role," she says. "They are interested in looking at the broader picture."
Her relationship with the GPs works to the benefit of her clients. "If someone who is a patient of the medical centre is attending me and if there is an issue regarding their medication then, with their permission, I can discuss that with the GP."
This discussion might result in a reduction in medication or it might result in a prescription for a client who had not been taking medication.
Her work covers a broad spectrum of conditions: anxiety, depression, eating disorders, relationship difficulties, children and families and coping with adolescents. "A clinical psychologist is trained to have a background in a number of different interventions and can choose the best one," she says.
Seeing a psychologist in a GP surgery, "facilitates communication", she says. "It makes it easier and works better for the client." But she regrets that her services are not covered by the medical card nor, in the vast majority of instances, by health insurance. "It's a real barrier to a lot of people."
Dietician Jill Kavanagh
When Jill Kavanagh began doing sessions at Seabury nine years ago, there were very few other dieticians working with GPs.
"Now there are 20 or 30 dieticians working in GP surgeries," she says.
Her clients come to her to reduce their cholesterol levels, to lose weight and for other dietary reasons.
"Type 2 diabetes is caused by being overweight," she says, so the success of her weight-loss treatment is crucial. "I feel they do very well in that clinic. It is my best clinic. It's very intensive and they see the same person every week. They build up a rapport with the dietician."
She has more time to give patients in the GP surgery than would be possible in a hospital setting. For this reason "you do better with the patients, you have a higher success rate." And she believes there is another factor: "They are paying you for the service and they will come back of their own accord. They are much more motivated than in a general situation."
The dietician service at the Seabury is private and is not covered for medical card holders. There are, however, some full-time community dieticians in the country who do sessions at GP surgeries and whose services are covered by the medical card.
"I would encourage more dieticians to set up with a GP," she says. "Most surgeries have a free room that they could use."
Similar services at more GP practices could cut hospital waiting lists: in parts of North Dublin "I understand you can wait up to a year for a diabetic type appointment. It's two weeks in the GP surgery."