Here’s how we overcome the GP shortage

Ireland is confronting a significant shortage of general practitioners (GPs), with the number of clinically active GPs failing to keep pace with a growing and ageing population. According to Medical Council data, the GP workforce peaked at over 4,800 in 2018 but declined to just over 4,500 in 2023, despite population growth of over 630,000 between 2014 and 2023. To maintain a reasonable patient-to-GP ratio (estimated threshold of 800–900 patients per GP), Ireland would need almost 6,000 GPs, indicating a shortfall of around 1,500–2,000 GPs in the coming years.

I’m so tired of politicians dodging these types of issues until they become a national disaster. Typically, if history is any guide, they will do nothing until this problem reaches a crisis point, and then we will get a shouting match with opposition politicians telling government politicians that they would have seen this coming back in 2025 and would have acted accordingly. Which is hogwash.

Terence Cosgrave

But if we had a proactive government (as they always claim) who, like everyone else, can see this problem looming in the future, what should they do?

There are options available to us to overcome this shortage. Let’s just examine the costs of each approach, and outline how the planning and implementation might proceed. (I do this without asking for any extra cash as a special advisor to the Minister) And let’s also pretend that AI doesn’t exist, because AI should change the paradigm dramatically.

GP numbers in Ireland have fluctuated, but the broad trend shows insufficient growth relative to population increases. In 2023, there were approximately 4,500 clinically active GPs, whereas to maintain the desired patient load ratio, nearly 6,000 would be needed. In short, we’re already short of the desired numbers.

Contributing factors include an ageing GP workforce (with around 32 per cent nearing retirement), emigration of newly qualified GPs (nearly 30 per cent emigrate annually), and insufficient domestic training capacity relative to demand. Ireland’s population is also ageing, and therefore experiencing rising chronic disease burdens, further increasing primary care demand. Geographical imbalances exacerbate the crisis: rural ‘medical deserts’ face acute shortages as younger GPs prefer urban or larger group practices in general.

Any response must address both supply-side constraints (training, retention, recruitment) and demand-side pressures (population growth, chronic disease, service models). In other words, how can we get more doctors, and how can we reduce the workload of these doctors?

Expanding domestic GP training capacity
One key option is to increase the number of GP training places in Irish medical schools and postgraduate training programmes. The Irish College of GPs (ICGP) reports an 80 per cent increase in annual intake over the past five years, with 350 places available from 2024. However, training capacity is constrained by availability of quality training practices, supervisory GP trainers, and funding for training infrastructure. Expanding capacity implies costs such as:

• Educational infrastructure: Additional funding to medical schools and postgraduate bodies for increased placements, training supervisors’ remuneration, and administrative support. Estimating €50,000–€100,000 per training place over several years (including stipend for trainees and supervisor costs) indicates a multi-year investment of tens of millions of euros for, say, 100 extra places annually. That’s not chump change. And that only gets us 70 doctors per year if 30 per cent ungratefully emigrate.
• Practice accreditation and support: Grants to GP training practices to upgrade facilities, provide teaching resources, and support trainee supervision. If each accredited training practice requires €20,000–€30,000 of support, and assuming 100 additional practices, costs could be €2–3 million.
• Curriculum development and faculty: Investment in educational staff (trainers, programme coordinators), simulation facilities, and assessment processes. This could entail recurring annual budgets of several million euros.
• Long-term yield: While upfront costs are substantial, additional trainees entering practice within 3–5 years would gradually relieve shortages. However, retention measures must accompany expansion to prevent leakage back to other specialties or emigration. We can’t be investing all this money simply to benefit the doctors and other countries. There’s no way the taxpayer is going to buy into that.

These investments must be covered in multi-annual budget allocations by the Department of Health and the HSE, and integrated into strategic workforce plans spanning at least a decade to be effective.

Retaining newly qualified and established GPs is critical. Thirty per cent of newly qualified GPs emigrate annually to countries like Australia, New Zealand, Canada and the UK. What’s the point in training GPs for other rich countries? We are throwing money away. We have no obligation to provide doctors with the training to make a good living in other First-World countries. We should stop doing it. There needs to be a linkage between the cost of educating these doctors and value we subsequently get from doing that.

Obviously, we need proactive and innovative thought here. We’re not the only country losing GPs. Why would they stay here?

• Financial incentives: Enhanced salary scales, retention bonuses, or loan repayment schemes for those who remain or return. For instance, offering €20,000 annual retention bonus for GPs in underserved areas could cost €20,000 × 500 GPs = €10 million annually.
• Grants for practice establishment: Covering setup costs (legal, premises fit-out, equipment). Providing grants of €30,000–€50,000 per returning GP in areas of shortage. If 200 GPs return under such scheme, cost ~ €6–10 million.
• Career development and work-life balance: Funding locum support for leave, flexible working arrangements, reduced administrative burden (investment in digital record systems, administrative assistants). Budgeting perhaps €5 million annually for locum pools and administrative support.
• Professional support: Continued professional development subsidies, mental health support programmes, mentorship networks. Estimating €2–3 million annually.
• Targeted outreach: Engagement programmes abroad, financial support for relocation, recognition of overseas experience. If travel and promotional activities cost €500,000 annually plus relocation subsidies (€10,000 per GP for 100 returning GPs = €1 million).
• Rural-specific incentives: Higher grants or allowances for rural practice, housing subsidies, tax relief, enhanced professional support. An additional €10,000–€15,000 annual rural allowance for 300 rural GPs → €3–4.5 million annually. Tiny money to give rural people their due – a local GP, who is often much more vital to them that his/her city counterpart.

Combined, retention and return schemes might cost €30–50 million annually, initially, but would yield longer-term workforce stability if structured with clear targets and evaluation metrics. That’s a good idea in the long-term. Irish governments rarely do anything that is a good idea in the long-term, but we can hope. And suggest.

Cost-effectiveness can be assessed against the economic and health system costs of unfilled GP positions (e.g., higher emergency department usage, delayed diagnoses etc.) Not to mention the moral wrong of not providing in rural areas what is commonplace in towns and cities.

International recruitment
Ireland has begun recruiting internationally: a joint HSE and ICGP programme recruited 114 GPs as of October 2024, with funding to recruit up to 250 more this year.

While international recruitment can provide quicker relief, it is subject to global competition for healthcare workers and may be less sustainable long-term. Budgeting in health should factor occasional surges rather than being solely reliant on help from abroad. In any case, we’re losing the international battle. Retaining Irish doctors should be the priority, but in the short-term, this is a quick fix, if not a very sustainable one.

Task-shifting and team-based care
Enhancing primary care capacity without increasing GP numbers would involve task-shifting. Doctors don’t want to hear it, but if they don’t have the time to do the job themselves, some other professional will have to fill the gaps:

Expanding roles for nurse practitioners, physician assistants (where applicable), pharmacists, physiotherapists, and others is an idea whose time has come. For example, integrating pharmacists into general practice for medication reviews or prescribing certain medications. Arguing against this and that a doctor must see every patient on every occasion is not tenable with the numbers we are looking at without some change. This is a binary thing.

Either we have non-doctors filling more doctor roles, or we have more doctors. If we can’t have the one, we must have the other.

What would this, could this involve?

• Costs: Training and accreditation of allied professionals (€5,000–€10,000 per professional), salary costs for additional staff in practices (e.g., hiring practice nurses or pharmacists at €40,000–€50,000 per year each). If each practice hires one additional staff member, for 1,000 practices, cost ~€40–50 million annually. It’s doable if it’s the right person/professional and they can fill some gaps. And, of course they can. It’s superstition to think of a doctor as some sort of priest and that only he or she has the divine right to prescribe or advise on a cold. You can either have this, or wait three weeks for an appointment. Where’s the triage?
• Digital health and telemedicine: Investment in teleconsultation platforms, remote monitoring, e-referrals to reduce GP workload. Infrastructure costs (IT systems, cybersecurity) might require €10–20 million initial investment plus annual maintenance. Potential long-term savings via reduced in-person visits. This is a culture change, but without more doctors, this is the future.
• Multidisciplinary teams: Funding for care coordinators and social workers in primary care networks. Budgeting €5–10 million annually for pilot programmes scaling up gradually.
• Training and governance: Developing protocols, legal frameworks for expanded scopes of practice; regulatory changes may be needed with investment in oversight (€2–3 million).

Task-shifting requires fairly robust evaluation frameworks to ensure quality and safety; initial costs may be high but can substantially alleviate GP workload and improve access. It also involves changing our attitude to what is expected of a GP – someone who will personally consult with each patient, or a manager of local health in the community?

Infrastructure and practice support
Supporting practice infrastructure, especially in underserved areas, is vital:

• Administrative and IT support: Funding for practice management systems, electronic health records, telehealth hardware. Annual budgets of €5–10 million for grants and maintenance.
• Locum and leave cover: Centralized locum pools to cover leave, reducing burnout. Estimated cost, €10 million annually. What a job that would be! One day in Montenotte, the next week in Crumlin, then Donegal. With a proper traveling allowance, you’re on your bike.
• Capital grants: For renovation or establishing new group practices or primary care centres. If capital grants average €100,000 per centre, establishing 50 new centres costs €5 million. Again, buttons for what it delivers.
• Primary Care Networks: Investment in community-based hubs where GPs collaborate with allied professionals. Establishment and operational costs of hubs might total €20–30 million initially. Again, well worth it.

These supports reduce barriers to practice establishment and operation, aiding both retention and recruitment. But what of the government’s plans to increase demand?

Extending free GP care increases demand and may exacerbate shortages if supply is not increased. ESRI estimated extending free GP care to all citizens by 2026 could generate 1.9–2.3 million extra consultations, reducing out-of-pocket expenditure but placing strain on GPs. No kidding.

Additional consultations require funding—either higher capitation payments, fee-for-service reimbursements to GPs, or salaried models. If average cost per consultation is €50, then two million extra visits imply €100 million annually in additional reimbursements. Without increased GP capacity, wait times worsen. Thus, free care expansion must be phased with capacity-building investments. And I’m way over-estimating here. Even the IMO know that you can’t charge €50 for a visit from a poor person that doesn’t have €50. You’re going to get nothing from that patient. So you can’t turn around then and charge your neighbours/the government/the taxpayers – €50 that you would never get in real life. So maybe €50 million here? Depending…

A sustainable response necessitates strategic workforce planning – projecting future GP demand considering demographic trends, disease burden, retirement rates, training outputs and emigration patterns. This approach ensures resources are efficiently directed and adjustments made as evidence emerges. It creates a shared view for the medical community and the public of what we think of our health system is and how we operate it.

It shows we are creating a system for all of the public, all over Ireland, and we are trying to make that the best system possible for everyone. If we could achieve that, no-one would begrudge the money required.

Overcoming Ireland’s GP shortage demands a multi-faceted strategy combining the expansion of domestic training, retention and return incentives, ethical international recruitment, task-shifting with allied health professionals, infrastructure and digital investments, and strategic workforce planning with multi-year budgets. Cost estimates indicate substantial investments—potentially hundreds of millions of euros over several years—but these must be weighed against the societal and economic costs of inadequate primary care (e.g., increased hospital burden, poorer health outcomes).

Not to mention the billions currently being spent on healthcare in Ireland and the increasing cost that is to the general economy. Or the fact that general practice has been much underfunded over the years and is due an increase on overall terms to reach a similar proportion to other wealthy countries.

A phased implementation with rigorous evaluation and stakeholder collaboration will be crucial to ensure that interventions effectively bolster GP numbers, improve access—particularly in rural areas—and sustain a resilient primary care system for Ireland’s future. But this must be government-led. No-one else has the responsibility or the ability. Ultimately, it’s down to Minister Jennifer Carroll MacNeil.

Continuous data monitoring and flexible adjustment of policies will enable the government to respond to emerging challenges and evolving healthcare needs. If they understand them. But we must get started now – like many health issues – to solve the problems of ten and twenty years’ time.

And all that’s before we start talking about the biggest change that will happen to medicine and life in general since the invention of the antibiotic – Artificial Intelligence. Look for the top ten ways in which AI will affect medicine in the July print edition of Irish Medical Times.