The annual general meeting of the NAGP took place at the Herbert Park Hotel in Dublin last Saturday and was a big success, achieving widespread media coverage for the plight of GPs suffering from FEMPI cuts. dr-andy-jordan

The conference was opened by NAGP chairman Dr Andy Jordan who referenced the beginnings of the organisation as the AGP and thanked members for their work in fighting for GPs in the past. He told delegates that €163 million had been taken out of primary care in FEMPI cuts and that while in other countries spending about 9% of the health budget on general practice seems to be the benchmark, in Ireland only 3% of the health budget goes to general practice “We must stop the madness and start caring for people within the community,” he said.

He said that members were collecting signatures from patients showing that they supported their local doctor and wanted to see general practice properly resourced. This book of signatures would be presented to the Minister in March.

He also told delegates that the organisation had voiced its opposition to the introduction of free GP care for children under six as this was being done on the back of the weakest members of society who would lose out if such a measure were introduced.

“If we are to get anywhere it will be through dialogue. The biggest mistake GPs have made so far is not getting the message out there,” he said. “Our most effective work to date has been our media work in making patients aware. Patients are the ones who will make a difference.”

He issued a rallying call to the members of the NAGP urging them to get involved in lobbying for proper resources. “General practice is dying. Make no mistake about it. We are saying ‘goodbye’ to general practice as we know it. You owe it to the patient population to stand up for them,” he said.

The conference was then addressed by NAGP CEO Mr Chris Goodey who outlined the strategy for 2014 for the NAGP in terms of raising public awareness about how important it is that general practice be properly resourced.

Mr Goodey has written a piece which was published in the Irish Times’ opinion page on the previous day which can be read here and he told delegates of the need for them to use the media to get their message across.

He told delegates that the most fundamental problem they faced is the survival of general practice as a viable and vibrant sector.

“Make no mistake, we are in crisis. We are shouting it from the rooftops, but no-one is listening. If we lose a sizable proportion of our GPs it will take years to replace them” he said. “In the North of this island, GPs receive three times the allocation in the budget that their southern counterparts receive. We have been trying to get the health Minister to listen to us as a group on this issue.”

Mr Goodey said the irony is that the policy of the Minister is to move more people into general practice while at the same time general practice was being starved of resources.

“I am sorry to inform the government, the public and you that there is no such thing as ‘free’ GP care. More resources need to be put into general practice. We need a government that is willing to listen. We have to start investing in the future of general practice.”

He said that the strategy of the NAGP in 2014 would be to “Engage, lobby, communicate and reform”.

“We are ready and willing to play a role in making general practice better but we cannot do that without resources, which are badly needed,” he said.

Keynote speaker

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The keynote speaker of the day was Dr Ed Walsh – the founding President of the University of Limerick and also a member of the board of Barrington’s Hospital in Limerick. His topic was “Adapting international best practice to transform Irish healthcare”.

Dr Walsh said he had spent the previous few weeks looking at the Irish healthcare system and he had concluded that he did not envy Minister Reilly’s task. In terms of money, he said that the State was ‘extracting as much money from the Irish population as possible” and that further increases in health spending were unlikely and unnecessary. He said it was best to ‘rule out spending more of the GDP on health as we already were spending enough.”

“Ireland has the highest hospital prices in the developed world and the most inefficient health system in the OECD,” he said. “We should slice another €1.7 billion to get to the average and a further €2 billion to be as efficient as New Zealand.”

The key to sorting out Irish healthcare was through smarter spending and redeploying resources, he said and pointed out that the health system employed as many people (101,000) as the city of Cork, but that only 8,334 were doctors. There were over 40,000 office workers in the system on an average salary of €70,000 and at least 25% of these should be let go with a saving of €1 billion.

This money should be used to provide more doctors in primary care. Only 25% of doctors in Ireland work in General Practice and in comparison “Ireland has half as many GPs per head of population than the norm across the OECD, and a quarter of the number of GPs per head of population when compared with Australia. He added “that in Ireland we have
 far too few GP’s intercepting problems where they should be intercepted. The key issue is the misallocation of resources,” he said, “we’re spending our money in the wrong place with too few doctors on the frontline and too many workers in offices.

He said there had been a failure to rationalise the HSE when it was created and a failure to put in an integrated computer system that would work across the system. The key actions required for reform were to increase the number of GPs by a factor of two and to increase the number of consultants by a factor of 2.5.

He also said that huge savings could be derived from introducing a state-of-the-art technology system and reducing the size of the administration. He cited the example of Estonia which has such a system and where patients only have to provide their information once. This could then be read by everyone in the system.

In Ireland, by contrast, people were filling in forms every time they encountered the health service and all this paper was being moved around by more people than was necessary.

“We are still dealing in paper and wasting hundreds of ‘man hours’ and the worst thing is that people who are running the system don’t know what’s going on because they don’t have the information at their fingertips. You could decimate the size of the workforce with a decent info tech system,” he said.

He also pointed to potential savings in the drugs bill and in cutting absenteeism which would amount to €1 billion. He also said that we had more nurses than the OECD average and that even though their numbers had been reduced by 4,000 we still had 6,000 more than the OECD average.

Dr Walsh’s comments were reported in The Sunday Independent which you can read here.

Health economics

Dr Tom O’Connor was the next speaker and he spoke on the topic “Ignoring your own Policy and Evidence: the government’s attack on the primary care system”. He pointed out that between 2008 and 2014 the government had taken €31.5 billion extra in taxes and spending cuts. Health spending in Ireland now was 8.5% of GDP and that were ranked 21st in spending on healthcare out of 29 countries. His opinion that there was little scope for more cuts in spending.

But he also maintained that the cuts had had an extremely negative effect and it was costing patients’ lives. “If we combine the cuts of €117 million on medical cards with the introduction of free GP services for the under-5’s, it is clear that the services for the relatively poorer and sicker people are being used to fund a universal service that has no fresh income stream of dedicated funding,” he said.

He also quoted several texts and references on how austerity programmes had on people’s health and said that Ireland was starting to move in the wrong direction. “The GP’s are holding the system together. Ireland has the 141 medics per 100,000 specializing in general practice, the second lowest of 26 ranked countries. Germany has 216, Spain 240 and the UK 192. GP’s keep people out of hospital beds,” he said.

He also noted that there had been an increase in hospital waiting lists since July of 96% and that Ireland had the fourth lowest number of hospital beds of 28 Eurostat countries.

“GP’s are central in primary care. There is strong evidence in HSE policy that GP’s are pivotal in sickness prevention and health protection ‘seemed to have gone out the window”, he said

He also examined the current situation with Primary Care Centres and said that they are not being built or being completed. “Are GP’s expected to this and become property developers?” he asked.

He also cited the example of elderly people who wished to remain at home and not go into a nursing home as an example of shortcomings in the system. 80% of old people could stay at home – they are low to medium management, he said, but this could not be done without the full resources of properly equipped primary care centres.

Survery of young GP’s

Dr Aifric Boylan then gave a presentation on research she had done on the attitudes of young GP’s.

It showed that half of all GP’s trained in Ireland do not work here despite the huge State investment of almost €200,000 in training each GP. It is the highest rate of doctors working outside their country of training anywhere in the OECD. The next highest is Luxembourg with 17%. In the UK, the figure is 6%.

Dr Boylan conducted the research and questioned 295 GP’s in training. Her research shows that of current trainees, almost a fifth will not practice medicine upon completion of their training (18%). Of the group of trainees, 8.8% plan to emigrate, 3.5% have already emigrated and 6% intend to change career.

Most of the trainee GPs complained of stress with 69% feeling undervalued by the State, 59% feeling that they were unfairly targeted by the media, and 51% cites difficulties in accessing hospital care for their patients. GP trainees also reported feeling overworked, feeling underpaid, and stress from the negative effect of their career on social and family life. Over 15% said they felt stress from feeling that they had made the wrong career choice

A further 24% of the respondents indicated that they possibly emigrate, with 7% saying they didn’t know, and a further 31% who were uncertain about emigration. Only a tiny percentage (3.5%) intended to open their own surgeries.

Panel discussion

There followed a panel discussion with Dr Andy Jordan, Dr Conor McGee, Dr Don Punch on the implications of this research.

Diabetes treatment and care

Following lunch, the focus was on the treatment of Diabetes. Dr Steve Davies, Consultant Endocrinologist at Cardiff University explained the success the Welsh had had in running their diabetes treatment programme.

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He said the Welsh situation was similar to Ireland’s in that they had a population of 3 million and that in the area of Cardiff, with a population of 510,000 they had 19,000 people with diabetes.

He pointed out that the diabetes population had increased enormously – 800% since the 1980’s and that the reason for this was that the UK had ‘become a nation of lazy porkers’. He said that with an increasing number of referrals secondary care was being overwhelmed and the Welsh had taken steps to treat many less complex cases of diabetes in primary care.

The model for this programme was having a consultant for every eight practices and giving two consultations per year. The Wales programme had been very successful with waiting lists reduced and no increase in consultant cost.

He pointed out that while diabetics are only 3.5% of the population, they consumed about 15% of all costs and this issue needed to be addressed.

Dr Davies was followed by Dr Christopher Poole – lecturer and researcher at Cardiff University. He examined the issue of diabetes from the health economics perspective. He noted that in Wales, the prevalence of diabetes was 3.4% but DM (diabetes mellitus) admissions were 12.6% and overall, DM accounted for 12.3% of cost.

He said that health economics was a ‘bit of a black art’ because giving a arthritic person a lot of expensive drugs to delay hip replacement might be a medical answer, but the best answer from a health economics perspective would be to allow them to fail and do the hip surgery earlier.

That said, he said, it was 20 times more expensive to use certain drugs over others and sometimes there was a small benefit – which hardly justified the extra price – and sometimes there was little or no benefit.

The cost-effectiveness of drugs in diabetes care is an important issue given the increased number of patients being diagnosed and he gave the example of human insulin – which is half as expensive as the analogue version. “Do the others give twice the effectiveness? No, they don’t” he said.

He said that there had to be a balance between the cost of drugs and the number of years of quality life they provided. This was illustrated recently by a drug for Cystic Fibrosis in Ireland, which gave a high quality of life to a very small number of people with CF, but the numbers were a tiny percentage of the people needing drugs in Ireland. “For the same cost, you might have built a hospital,” he said.

“Doctors may not be providing the best therapy in prescribing certain drugs, but they are prescribing in the fairest way possible,” he said.

The final speaker on diabetes was Dr Ronan Canavan, consultant endocrinologist at St Vincent’s Hospital and Diabetes Lead for the HSE. He discussed the Irish approach to tackling the issue of diabetes since the national clinical programme had been set up in 2009.

He said the programme was measured by three parameters – access, quality and cost. In Ireland, 5.6% of the population have diabetes but the estimated number with Type 2 DM would increase by 60% in the next 10-15 years. He noted that 10% of the Irish health budget is spent on diabetes annually – €1.35 billion.

Diabetes in patients under 40 was more complicated, he said and €816 million was spent on complications. However, the National Diabetic retinopathy screening programme was working and that a register had been compiled of 145,000 patients.

There were seven treatment centres and 3,000 invitations were being sent out per week. The target for 2013 was to invite 30% of the 145,000 patients and they were on course to achieve this.

He said there was now an integrated diabetes care package in place and that the plan was that all patients with Type 1DM would be managed in secondary care, while uncomplicated Type 2 patients would be managed in primary care.

Complicated Type 2 patients would be managed between primary and secondary care.

The meeting ended with the annual general meeting itself.