maitiu-resize-1-of-1-300x300

General practice training is still reeling from the news that the 2017 trainee recruitment process managed to fill only 176 of the proposed 186 places. This is an unprecedented scenario whereby GP places were neatly always oversubscribed by a factor of nearly 2:1.

There has been much explanation as to the possible cause of this, including the late and hurried expansion of places which saw each scheme take 1 additional trainee.

The ICGP plans to increase trainee numbers to 200, and beyond is now unrealistic and young doctors are perhaps not seeing General Practice as an attractive career anymore.

The knock on implications for General Practice, healthcare in the community and patients is huge.

Why such a shift away from general practice training amongst graduates?

Just ask the current general practice trainees.

General practice in Ireland at the moment is awash with uncertainty. General practice trainees are a confused bunch. Most have no idea what the future has in store. What was once a popular option for doctors is becoming less so, all because of this uncertainty. The future viability of the profession is in question.

Why are trainees so uncertain?

Very little in general practice today is clear-cut. The future governance of general practice training is due to change. The expansion of the under 6’s scheme to the under 12’s and possibly to the under 18’s seems to be on hold. Our current contract, and its negotiation/ or non-negotiation seems to be progressing and going no-where in equal measure. The HSE will be replaced, but with what remains to be seen. How will this effect general practice? Does anyone really know?

What does all this uncertainty mean for trainees? The talk among my colleagues currently is of whether we should stay or go. This isn’t a new conversation, but I feel it’s a conversation that’s becomingly increasingly common amongst us, and an issue that many are choosing to ignore, not out of ignorance, but because it’s a complex issue that’s not easily solved.

What do the figures suggest? The ICGP has recently repeated its ‘”Bridging the Gap” survey.  The 2015 version of this survey stated clearly that only one third of trainees planned to definitely stay in Ireland. This was pre-the under 6s, pre contract negotiations and pre Brexit / Trump. Over half were possibly going to emigrate or remained undecided. Why so? The viability of general practice was the single biggest reason stated, second only to financial reasons. So nothing has changed in the interim, just that things have become a lot less clear.

Why not settle for the general practice of today?

General practice in Ireland is currently at tipping point. Just look at out of hours. Waiting rooms bursting at the seams, and appointments, which extend into the early hours. Christmas just past, saw appointments in our local CO-OP continuing until five in the morning.

Same day appointments are rapidly becoming a thing of the past. I know in one town not so far from Dublin where the waiting time for a routine appointment is three days. And this is within commuting distance to Dublin. What will happen in west Clare? Even I, with very little general practice under my belt, have seen a significant change recently. In the town where I currently practice, all the GMS lists are full. Where are these patients to go? Out of hours? What happens when out of hours is full? The Emergency department? The emergency departments are already full? Should we start suggesting to our patients that they consider emigrating to somewhere where waiting lists are shorter? I hear waiting lists are non-existent in Scandinavian countries. Maybe that could be the next campaign to take over form undertheweather.ie, one-way tickets to Sweden.

Recently, the slainte care report was published. It recommended extension of free GP care to all. We all agree with this in principal. But somewhat limited access to something is better than unrestricted access to nothing.

The new contract

What about this new promised contract? Simon Harris seems to think it will solve all our problems. And some. He does genuinely seem to believe in the process with conviction. But word on the ground is that talks are going nowhere fast, and the timeline has gone from months to years,

Much discussion amongst trainees is focused on who is negotiating? And what are they negotiating for? Is anyone representing the interests of trainees?

The IMO and NAGP are negotiating separately, for various reasons. But what about the trainees? Has anyone thought about that they want? The future of general practice is in their hands after all. Could both unions not work together in the hope of achieving a common goal? I think its time we all focus on the future viability of general practice, and not on parish pump politics. We all want a general practice worth staying in Ireland for. We have similar goals, hopes and aspirations. I don’t see why we can’t work together to achieve these. After all, are we not stronger together? No progress will be made as long as we remain divided.

A new contract or a rehashed old contract?

Do we want a new contract or do we want to add things onto the old contract. Will an extra STC here and there solve the issues in general practice? Or do we need a new fit for purpose contract? I believe we need to focus on the bigger picture – that is a new contract. Not bolting STCS onto a contract, which was thrown together in a time before mobile phones, laptops and the Internet.

The current negotiations are going to decide what the general practice of the future looks like. It’s about the future of general practice, as we know it. It’s as relevant to current trainees as it is to those who have fought the hard fight for the past 30 years. Possibly more so.

What do we want? More of the same?

I find it interesting when those of us who aspire to some day be principals meet those who have been principals for a quarter of a century. We are about the terms and conditions. They’re about the bottom line. (Which is understandable as many are heavily indebted thanks to the boom times.). We both want patients to get the best care possible.  We can definitely meet in the middle. But let us.

Single-handed GPs? Only 2% of current trainees see this as being an option in the future for them. We must come up with alternative, viable options to the single-handed GP.

Annual leave? Study leave? Locum cover? A viable pension. What about these?

Trainees want to have realistic and functioning annual and study leave, as well as a viable pension. After thirty to forty years of working, is that too much to ask for? Our hospital colleagues are graced with these entitlements. Are we just not worth it? If this isn’t addressed, the lure of life in Canada or Australia seems just too strong. We are happy to take over chronic care in the community, but could we get a transfer of resources and leave entitlements too? Surely the community-based physicians that will manage all this chronic care on top of their current roles deserve a break too?

Flexibility

We need a contract that will allow trainees to work part time, and work flexibly.

Our workforce is becomingly increasingly female, and I say thank god for that, because they wont put up with the ridiculous conditions that the men of days gone past have.

The 2015 ICGP Bridging the Gap survey revealed that only 40% of graduates saw themselves working full time in general practice ten years after qualifying.  The current contract doesn’t accommodate this at all. We need to let our graduates work in ways that suits them, otherwise the Canadians and Australians will.

The system as it currently stands is inflexible, and doesn’t accommodate those who want to work part time or flexibly. The only option in these cases is to work as a salaried GP, or as is mooted by many current trainees, work for one of the emerging corporate conglomerates, that are becoming the new emerging face of general practice in Ireland. I have my own thoughts on this, but feel, as a minimum that we as trainee should have options.

GPs with special interests?

Trainees are being pushing for increased educational supports. Trainees want to up skill as much as possible. Many are now completing two or more diplomas per annum, during their training. These are hugely expensive. Many are over three thousand Euro. Trainees do get €500 per annum towards these, which does help, a bit.

I believe that if GPs are going to agree to chronic care management then a stipulation to this agreement should be funding to up-skill and train ourselves. It goes without saying that this money will pay for itself exponentially in the long run. Up-skill general practitioners, give them the knowledge and skills to mange more in the community, and make them less dependent on the hospitals. Is this not what everyone wants us to do? Inter-GP referral isn’t yet common practice, but giving the fact that waiting lists for some specialties extends into years, it would be reasonable to ask for the opinion of a GP with a special interest in a certain topic, for example dermatology.

Many trainees want to develop special interests but this is not financially viable, as it is not recognised in the current contract. Some trainees would be interested in doing 1/2 session per week in emergency departments, ophthalmology, sports medicine, medicine for the elderly or dermatology. The GPSI, works well in the UK, Australia and New Zealand, and many trainees who consider emigrating, mention this among reasons for leaving. This can only be addressed by way of a new contract that is fit for purpose, and recognsises the general practice of the 21st century.

The indebted graduate

General practice remains very attractive for graduate-entry medical students. It’s a quick, four year run through scheme, with a guaranteed job at the end.  So why do many of these graduates emigrate? It’s simple mathematics. Most of these students are heavily indebted once they’ve passed through college, in many cases these students are €150,000 plus in debt. Now that most hospitals are European working time directive compliant, most interns start out on €30,000 per annum. Even with a hefty call schedule, most can at best hope to make €40,000 in their intern year.

General practice registrars make about €650 per week after tax. This isn’t bad, if you’re debt free. Throw in average Dublin rental prices, €750 per month, a car loan, which is a necessity, €300 per month, and day to day living expenses, there really isn’t much room to pay back that huge loan. Solution? Emigrate to New Zealand / Australia / Canada, where graduates are being tempted by well paid jobs in more rural parts of those countries. The temptation to emigrate and work hard to clear that loan as quick as possible is very tempting, and in some cases, is the only viable option.

Chronic care: The hot topic of the moment

85% of trainees support the move of chronic disease management into general practice, if, and here’s the caveat, its appropriately resourced and supported.

We are far far from that.

I am unsure how I feel about managing COPD in the community if I don’t readily have access to Spirometry (which is currently the case). I currently do not have access to a BNP blood test (in 2017! – the mind boggles), or an echo, so how could I possibly manage Heart Failure with any degree of accuracy? Would a cardiology intern be expected to manage a heart failure patient blindly without a BNP or a respiratory intern be expected to manage a COPD patient without a spirometry result?  I can do bloods two days per week. A CRP is consultant only. I am happy I can spot an exacerbation of rheumatoid arthritis clinically, but surely the hospital doctors would expect us to do a CRP? No? GPs will no longer be able to organise private MRI scans, as they’re soon to be consultant only for private patients. CT scans are already consultant only in the public system. I would expect my patient with dementia who I would manage in the community, all part of my chronic care, to get a CT Brain as part of their work up. Is that unreasonable? I think not. And neither do our trainees. They are more than able to manage our chronic disease patients, but let us do it properly.

I don’t believe in its current guise, that general practice is anywhere near ready to accept chronic disease management. Lets agree to do things right for once, and transfer the resources first, and the patients afterwards, to ensure we do it right. Lets not rush things. Our chronic care patients are currently being managed in the hospital, so there is no sense of urgency here.

What about the training?

General practice is a great career, it allows doctors to develop and adapt their practice in any way that they want. It gives doctors autonomy, independence and to some degree, control of their destiny.

The training is great, probably the best training scheme in the business, with an unrivalled “one entire day” of teaching in years 3 and 4. We have one to one mentoring with our trainers, again something that many in hospital can only dream of. The current talk of transfer of tasks from doctors to nurses, which is currently pitching NCHDs against their nursing colleagues isn’t an issue in the community.

There is huge uncertainty over the transfer of administration of general practice training from the HSE to the ICGP. No one is clear what this new system will look like. The latest update we have received is that this transition will occur from July 2018. But will it? Previous deadlines have come and gone. Trainees are genuinely worried about this. Rumors are that many of the programme directors and their assistants are worried about this change, as many will have to re -interview for their jobs, so there is a genuine fear, that many of us will loose the highly experienced mentors we have worked with for the past few years. This would be a huge loss of experience if this were to be true.

It seems, on the face of it, that the ICGP has agreed to train more trainees for less money? We are told that savings will be made in “avoiding duplication and in administration”. I have heard many trainees ask “Why would anyone agree to this?  Do more with less?”. It’s a fair question. This hasn’t done much to reassure trainees. Did anyone ask them for their opinion?

General practice training in Ireland is second to none, and continues to produce world-class doctors that are in demand, worldwide. I would hope that this remains the case into the future. At the moment no one can be sure of this.

What’s the solution?

The solution in the short term is unclear. In the interim, the ICGP has decided that it will steadily increase the number of trainees in training. The government is happy with this. It ticks the box.

Simon Harris will tell you “it’s a very complex situation.” I would argue that’s its not. We have a bucket (the health service) with a hole in it (emigration). Water is pouring out (graduates). We can continue to pour more and more water into it (the current plan – just train more doctors) or we could try plug the hole? (Give them certainty, and a new contract, and keep them).

Water is probably not a great example to use, given our recent disastrous management of Irish water. Will we learn from this? Probably not. But we should try to, and not repeat the mistakes of the recent past.

It would be cheaper long-term to retain all our trainees, rather than continue to churn out more and more in increased numbers without dealing with the major issues that deter trainees from staying here.

I feel GP’s are, by their nature, too complacent, too focused on patient care, which is what they do best, and willing to do more and more with less and less. Why else would we be left with a contract that predates most, if not all our current GPs medical training? We need to push for change. Otherwise, Will the last trainee please close the door behind them and turn off the lights?

Dr. Maitiu O’Tuathail

NAGP GP Trainee Representative