November 25 2018
During this past year, I have visited 250 GP surgeries around the country. I have seen at first-hand the operation of the General Medical Services (GMS) – the medical card system that serves Irish people – in rural and urban areas and how it affects both doctors and patients.
It is currently near, or to be honest in, a state of collapse. The existing system pushes most GPs into a predicament whereby, in order to make their practices viable, they must accept large numbers of medical card holders.
The result is a system whereby GPs are vastly over-worked and patients are placed at unnecessary risk. The system needs urgent reform. But that’s hardly a secret to the powers that be.
There are approximately two million patients with medical cards, or GP-visit cards. Over the past eight years, the number of medical and GP-visit cards has increased by 40pc. So doctors are expected to do a lot more, with an awful lot less.
Over that same period, under the cuts imposed by the Financial Emergency Measures in the Public Interest Act, funding for general practitioners was cut by 38pc. It has never been restored, and this has led to the current crisis.
Due to workload pressures, many GPs have been forced to close their doors to new patients. It’s going to get much worse unless the Government acts. The warning signs have been there for many years.
I visited a family doctor who has 1,000 medical card patients on her books. I asked her how she manages. Her answer was simple: “I come in at 8am, and I leave at 10pm, every day.”
I explained that working a 70-hour week isn’t sustainable for herself and it isn’t safe for patients either. She agreed, but could see no other way. “I will keep going until I burn out,” she said.
The burnout rate among GPs is very high. The majority of the GPs I visited are best described as tired, worn-out, fed-up, disillusioned, depressed and ready to quit.
The evidence of this is all around us, particularly in rural Ireland, where dozens of communities have no permanent and full-time GP service. I have met doctors as they, first, closed their patient lists; and later, closed their doors, because their practices were not financially viable.
There was a time when communities in Ireland always had three key pillars in their midst – a priest, a bank manager and the local doctor; all highly valued. In some cases now, only the GP is left. Soon there will be many places with no GP.
The old image of the GP as the pillar of a local community, running around the country doing house calls or being seen down the local golf club is long gone.
The modern GP in Ireland is so stretched that they are missing out on family life – and house calls are now predominantly a thing of the past.
When I asked our GP members what they do in their spare time, the answer was consistent; they don’t have any spare time.
I also look at the age profile of GPs and can see only a demographic time bomb. Our population is getting older and so are our family doctors. Around 700 (17pc) are due to retire in the next five years.
We train around 180 GPs a year, but half of them emigrate soon after graduation. So if you don’t already have difficulty getting an appointment with a GP, you certainly will in the years ahead.
In the most recent Budget, the Government announced 100,000 new GP-visit cards. It was done without any consultation with us, the professionals who must provide the service to those extra patients.
Politically, of course, it was a great move. But medically, it will probably do more harm than good because there are no extra doctors, or any extra funding to serve these patients. It’s like the Government giving away free membership to a gym that is already at capacity.
We believe that Ireland needs a health system where patients see the right healthcare provider, at the right time, in the right place, at the lowest level of complexity, and close to their homes.
However, we also believe that free doctor visits leave the system open to some potential abuse. A small co-payment would free-up waiting rooms considerably. People value something when they contribute something.
The National Association of General Practitioners supports the basic principles of Slaintecare – the 10-year plan to reform health. But there are urgent investment measures needed now in primary care.
Ireland’s record of delivering on major health strategies is not good. We talk the talk but won’t put the funding in.
To understand the solution to the problems in the Irish health service, let me share with you probably the most important concept in medical economics: The cost of treating a patient in a hospital bed is €1,200 per night; while the cost of treating a patient in their own bed is less than €100 per night.
Or, according to a recent paper published by Deloitte, we know that every €1 invested in primary care saves €5 in the rest of the health service. Think about that.
Every effort should be made to keep patients out of hospitals; hospitals should only be for people who need to be there. This is where GPs are key.
In many cases, patients are sent to emergency wards for such matters as sprains, minor cuts and minor illnesses. This places unnecessary pressure on the hospitals and creates long waits and very unsatisfactory conditions for patients.
Everyone accepts many patients seen in hospital emergency departments could be treated by their local GPs, if sufficient resources were put in place. But the powers that be continue to ignore all the evidence that is presented.
Some patients need long consultations to tease out their complex medical and psychological issues. But this is not possible when there are a dozen other patients waiting to be seen.
Almost every doctor I meet talks about the ‘near-misses’ that take place when patients don’t get the attention they require, or indeed, when the doctor’s judgment is affected by working 70-plus hours in a week.
In a recent survey by the Irish College of General Practitioners, 52pc of GPs said they would opt for another career, if they could choose again. Over 66pc stated they would advise their children to follow a career other than general practice. Around 31pc planned to leave general practice in the next five years.
It is easy to lash out at the Department of Health, the HSE and Minister Simon Harris. However, the health service is far too big to have its successes or its failures attributable to one person.
It is disappointing that the current regime has not yet at least laid the foundations of meaningful change in primary care. The minister may point towards Slaintecare as a step in that direction – and indeed, it is visionary.
However, until such time as general practice is adequately resourced, and a new contract in place, Slaintecare will remain just what it is: a vision.
A crucial step is to engage with the NAGP to construct that new contract. We represent close to 2,000 family doctors but remarkably we are excluded from negotiations with Government. We want to be there, we are ready to negotiate – but we have been frozen out. That is unfair, unjust and needs to be explained.
Any major reform of the GP service must carry the support of the body that represents the most members, to ensure total buy-in to change.
The fact is that the NAGP represents significantly more GPs than the Irish Medical Organisation. Yet Minister Harris’s officials refuse to engage with us – the only union that is dedicated to general practice.
Instead, they give preferential treatment to the IMO. The NAGP deserves equality of treatment and a place at the talks table to help secure changes to healthcare that patients need.
The current system, inadvertently, puts thousands of patients in the wrong place at the wrong time.
There are people at home, who should be in a hospital.
There are people being treated in hospitals who should be treated at home.
There are people in emergency wards who should be in their local health centre.
When the NAGP paints a vision of better primary care services, we are not talking about adding to Ireland’s healthcare cost; we are actually proposing ways to reduce it.
Every time we treat a patient in their community rather than in a hospital, we are making big savings for the HSE, and ultimately for you, the taxpayer.
Everyone agrees that healthcare reform in Ireland must involve a move to more community-based care. This model of care, calls for much greater support given to our highly trained specialist GPs, allowing them to work to the absolute top of their licence.
The case for a massive shift in spending from secondary healthcare to primary healthcare is beyond dispute. It will eventually happen in Ireland, just as it has happened in all of the best performing health systems around the world. But when, minister? Patients can wait no longer.
The NAGP is ready and willing to take a responsible approach to reform of the family doctor service.
But when will the Government open its doors to hear our contribution?
Chris Goodey is chief executive of the National Association of GPs. www.nagp.ie