So where is general practice after eight years of “Doing less with less”. FEMPI commenced in 2009 and unfortunately the Government singled out General Practitioner Services for the most drastic cuts of all. This is decision has had disastrous consequences for the profession and for patients.
General Practice and Primary Care were identified as the solution to the problems with our healthcare system. The Primary Care Strategy was published in 2001 and outlined a strategy which placed General Practice at the heart of the solution– We had a plan – They knew it was the solution. Other countries had already made the decision to resource G.P services and Primary Care to address escalating healthcare demands and deal with spiralling costs in secondary care.
No other Government in modern times has reduced funding in General Practice or Primary Care as a cost saving strategy. It has proven to be a historical miscalculation. Now we have hospital wards full of patients with multi morbidity and frail elderly patients. We have the highest per capita nursing home population in the OECD. We have 560,000 patients on waiting lists for OPD. We have 80,000 patients on surgical waiting lists. Hardly any elective work is being done in our Public Hospitals as beds are being filled by EDs. We have no statutory Home Care system in place. Young GPs are fleeing and do not see General Practice in Ireland as a viable career.
To compound things even further, an increasing number of our G.P trainees are postgraduate entry candidates and carry large student debt of the order of €100,000 to €150,000. The NAGP has built a very strong relationship with GP trainees and we see them as the future lifeline of General Practice. They simply cannot afford to stay here! During the past year we met with various politicians to advance the cause of the debt ridden GP trainees and suggested various solutions such as grant type supports to reduce the medical graduate debt in an effort to help these doctors remain in Ireland. Plans are in place to increase the number of places on the training schemes up to 240 but this is all meaningless unless we can stop the exodus and fix General Practice. Unless we do that very fast all we are doing is training GPs for export and at the same time our reliance on international medical graduates is among the highest in the OECD accounting for 38% of the workforce.
This is all against a backdrop of a GP shortage. The Medical Councils Workforce Intelligence Report tells us that there are 63.1 GPs per 100,000 population practicing medicine in Ireland against international best practice figure of 80 per 100,000 population. General Practice delivers 22 million consultations annually which is projected to rise to 33 million over the next 5 years. The LHM Casey McGrath report commissioned by the NAGP in 2015 estimated that 2954 GPs were working in Ireland and to meet the increasing demand we would need 4264 GPs by 2021. Speculative reports indicate that up to one third of the workforce may retire or just stop working over the next 5 years so the problem is a true crisis.
No sensible Health Economist would argue against the notion that General Practice and Primary Care is the solution to a lot of the problems in our Health Service. Contract arrangements between the state and the General Practitioners are archaic, and to people outside of medicine seem laughable and unbelievable. Rural General Practice is failing. Remote areas are no longer guaranteed local G.P services. Urban deprived General Practice is failing the most vulnerable people in society.
Over the past two years the NAGP joined forces with other health and social care professionals in the Primary Care Partnership and we just had our second conference four weeks ago in Croke Park. International speakers and opinion leaders from all over the world who spoke at the conferences all have the same message- General Practice and GP led Primary Care. All countries who are making progress with their health care systems are investing heavily in General Practice and Primary care. While less than half the population have GMS cover we must remember that the system is front loaded with illness due to the discretionary medical card system so a huge volume of the work ends up being carried out under the GMS.
I want to see an end to this top down approach we seem to have inherited in Health and replace it with a bottom up approach. The success of the GAA must surely be its grassroots bottom up approach – that sense of buy in and ownership that exists because of that approach. The ICGP can inform and advise on best practice and insist on standards in any new contract – this would be welcomed by all right thinking people involved in the contract process.
There is no vision. There is no plan. There is a lot of talk. The ten year Future of Health Committee are due to give us their vision this month. Dr Michael Harty gave us an insight in to the likely outcome of that Committee’s deliberations. I hope it will be properly costed. The Dail will have to discuss it and finally agree on it. There will be legislation to underpin it. Then we will have to live with it.
The NAGP has argued the need to ring fence €500 million per year for 5 years for investment in GP led Primary care. The Deloitte study in the UK outlined that for every £1 spent in Primary care a saving of £5 is achieved elsewhere. As we move towards better resourcing of General Practice we need to develop nursing capacity to assist in new models of care for chronic disease management. The move from managing chronic disease in the hospital setting in to General Practice will take time, extra resources and extra staff.
We have looked at telemedicine in all its forms and have come to the conclusion that it is here to stay. We feel the best model is the one pursued by our own GP Online suite which promotes the concept of the patient interacting with their own GP in video health consultation. We had demonstration of the App and the Video Health consultation experience at the recent Primary Care Partnership Conference and will have further demos here today with our partners in the project Promed. The major advantage is that the doctor has the patients full medical file in front of him while consulting with the patient. The lack of this doctor patient relationship in other offerings in the market place is their main weakness and possible danger to patients.
The policy of the NGAP is to advocate for patients; to “Put the patients first”. Our vision remains the same – we believe in patient centred, G.P led Primary Care, embedded in the community. We need to take ownership of General Practice and control the governance of G.P services. It cannot continue that HSE management, with little understanding of the day to day challenges of GPs and their patients should have control of how General Practice is managed.
General Practice is in crisis and a new contract will only materialise when the roadmap for the next 10 years is agreed.
General Practice needs to be rescued urgently – for the sake of GPs who have dedicated their careers to the care of their patients; for the future of the profession and in the best interest of the people of Ireland.
We need immediate reversal of FEMPI in line with what is happening in other organisations. The really odd thing about FEMPI in General Practice was that it was the patients that suffered. This was patients money that was taken away. No further un-resourced work will be accepted by G.Ps.
We must see the reversal of FEMPI. We must negotiate a new GMS contract. Personally, I want to see the NAGP and the IMO present a united front to contract negotiations and work together for the betterment of General Practice and patient care.
In a Utopian Society free healthcare is a fantastic idea. General Practice is on its knees. We do not have the manpower or resources to provide this model of care at the moment. We have a huge challenge ahead of us – We must fix General Practice .
You need to leave here today with fire in your belly and go back to your colleagues across the country and encourage them to stand up and fight for General Practice. I believe General Practice has a bright future because we must fix it. We have no option; because without it the system will crumble completely.
Dr. Andrew Jordan.