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Context
Ireland has one of the most rural populations in Europe1. Rurality, like any other social determinant of health, presents challenges to accessing health services, but should not be perceived as ‘problematic’ and in need of a structural fix. In health discourse, social determinants are often discussed as barriers to seeking health services (eg geographic, economic, racial, political). While many of these find their roots in structural violence, economic, political, legal or religious social arrangements that put individuals and populations in harm’s way2 require a culturally sensitive response2,3. Structural urbanism, where health care is viewed as a commodity for individuals rather than an infrastructure for populations, innately favours larger urban populations and has detrimental outcomes for rural health4. Preserving what is integral to the identity of a community, while re-creating systems that work in tandem to deliver equitable outcomes, is challenging but socially justifiable. In this article we present a brief account of advocacy led by rural GPs and their communities in Ireland, and the political and policy implications of their efforts.
Issues
The primary care team serves as a first point of healthcare contact for rural communities in Ireland. The GPs clinic is a one-stop shop for all healthcare needs, including a dispensing function in remote parts of the island5. Ireland does not provide universal registration with a GP. Almost half of the population are registered through the Primary Care Reimbursement Service (PCRS), which funds general practices on a per-capita basis6. The remainder are private patients. In many places, the rural GPs, nurses and their families reside in the village itself and are integrated with the community, and often the only immediate medical aid available1. The indispensable nature of a rural general practice can be summarised by the observation ‘If you wish to see a rural community die, kill its healthcare’7.
In the period 2010–2016, Irish rural general practices were struggling for viability. Two key financial supports to practices were distance coding and the Rural Practice Allowance8.
Distance coding is a particular financial reimbursement for PCRS-registered patients relating to the distance they live from a particular practice. The Rural Practice Allowance (at a maximum financial allowance of €20,000 per annum) supports rural GPs who run practices in low population density areas to take annual and study leave, get GP locums and support indemnity contributions7. Unfortunately, distance coding was removed as a financial support by the government in December 2010 and after that several rural practices failed to retain their Rural Practice Allowance8.
These practice supports for Irish rural general practice were as indispensable as the practice itself8. Facing a crisis of imminent closure, rural GPs turned to the political system by presenting their case to a committee of government representatives9.
Despite assurances, demands to reinstate the rural practice allowance and distance coding were ignored. This directly contributed to the founding of the 'No Doctor No Village' campaign in Ireland during the general election of 20169. As the campaign gained momentum, and when it seemed likely that a rural GP would take a seat in parliament, a new Rural General Practice Framework was announced. This was timed for release just days before the election itself. This new framework expanded the criteria for inclusion of practices in the Rural Practice Allowance and significantly increased the quantum of the grant available9.
This campaign highlights the agency of patient populations and communities, which is often overlooked by policymakers. While rebuilding rural health care requires financial investments, addressing urban narcissism that shrinks rural realities and lived experience requires the same focus10. Communication and community participation are key in delivering adept policy outcomes, but they present with their own challenges11. Fruitful involvement must be focused on building long-term partnerships as opposed to tokenistic, project-based consultation11. Developing shared definitions, goals for progress and delegation of real decision-making power to the community is messy but leads to meaningful rural health policy outcomes11. It is hence of consequence to collaborate with rural patient populations, creating a ground-up structure for advocacy in line with the idea ‘nothing for us, without us’.
Following the 'No Doctor No Village' campaign the Rural Practice Allowance was expanded to cover a larger number of rural practices and took shape as the Rural Support Practice Framework12. A significant headway, this allowed rural GPs to continue providing essential services in remote parts of the country. However, the larger recruitment, retention and replacement crisis continues to be an obstacle to equitable access to GP services for rural Ireland8,13. Although rurality looks different across various contexts, the issue of sustaining high-quality health care for rural populations is akin to that of other countries, whether high income or low14.
A further key initiative involved inviting young doctors to step forward to mentored leadership roles in rural advocacy. This was exemplified by three young doctors from rural placements being given the opportunity to become mentored delegates at a leading world rural health conference, and jointly authoring a blueprint for their own success. The World Rural Health Conference held in June 2022 at the University of Limerick invited over 600 expert delegates to contribute to the authorship of the Limerick Declaration, a blueprint for preserving and advancing rural health in Ireland and internationally1. The declaration is more than just a policy piece. It finds commonality across the motivation, perspective and experience of unnoticed stakeholders to generate a roadmap for a pressing issue nationally.
The Limerick Declaration has also created a new momentum in advocacy for Irish rural general practice. Funding totalling €760,000 has been secured from national health agency the Health Service Executive for four 2-year rural postgraduate fellowships in Irish rural general practice under the auspices of the Irish College of General Practice (ICGP). The GP College board also approved the creation of a new Standing Committee for Rural General Practice, which will take a lead role in advancing education, training, research and advocacy for Irish rural GPs and rural communities. In addition, the non-EU GP Initiative for Rural General Practice has been launched, whereby physicians who have received GP training in non-EU countries will be provided with a pathway to GP principleship in Ireland. Since the blueprint, instrumental policies such as the ICGP’s Shaping the Future document have been rural-proofed to ensure they align with rural development13.
Lessons learned
While significant breakthroughs have been made in sustaining Irish rural general practice, the issues are anything but resolved. Advocacy – whether through community mobilisation, research, conference delegations, rural-proofing policy or action – requires consistent, purposeful efforts with a relatable appeal. Measures such as rural-proofing must promote social cohesion across sectors and be the first step when creating policy, not the last step on a checklist. Advancing rurality as opposed to adopting a mitigatory approach has been central to the efforts outlined.
Local voices have driven monumental change in the Irish healthcare context. For these communities, the policy and politics of rural health are mere tools to maintaining or restoring their way of life. Similarly, a social justice perspective would compel us to adapt to and not oppose what is relevant to a community. The biggest lesson to be learned is that unrelenting community commitment, when supported by the capacity to advocate, can influence politics and policy to generate sustainable outcomes and thriving communities.
Funding
No funding was received for this research
Conflicts of interest
The authors declare no conflicts of interest.