Dear GP Colleagues,
We are only too well aware that many GP colleagues are under huge financial pressure in their practices. They are being offered a short term financial gain or a lifeline to keep themselves afloat by agreeing to accept a contract that the majority of GPs agree is morally & ethically wrong when State resources are so scarce and a contract which has major long term implications for the future of general practice in Ireland. Certainly for any GPs within a few years of retiring, this contract is very enticing with the probability of a short-term boost in income and pension. GPs are understandably conflicted.

We implore you to read the contract very carefully and to take as much time as you require in consultation with local colleagues before coming to a final decision. Some of the oldest words of wisdom are “Act in haste, Repent at leisure”.

Do we want our legacy to be that we grabbed the cash and ruined general practice in Ireland for our patients and the next generation of GPs.
Regardless of whether you are a member of the IMO, NAGP, ICGP, all or none of the above, the only reason you are reading this is because you are a GP. That is our common bond. Together, anything is possible. When reflecting back on his life, Nelson Mandella said: “It always seems impossible until it’s done.”  As we each reflect on this contract, we must try to see the bigger picture and not be afraid to make the hard but the right choice.

1. This contract as a template for a new GMS contract?
Clause 41.1: “This contract is intended to be an interim contract”
Clause 41.2: “In the event that a new GP contract is not agreed” a review will commence on 1st August 2016.
The General Election must be held by May 2016 at the latest. Any leverage we may have Pre Election will have disappeared once the votes are in. This present Government and all political parties support the concept of “GP care free at the point of use for all”. The only point of disagreement is how to do it and which groups to extend free care to first.

The present Government has set out its timetable quite clearly and repeatedly. Post-election whatever Government/Minister we have, they will be under no pressure whatsoever to even talk to GPs. Despite current spin, the Country is still in huge debt and many many calls will be made on Government from all angles. In this contract, the Government has only committed to a review. That review – if it even occurs – is quite likely, at best, to recommend to maintain the status quo if this under-6s contract has been accepted and implemented.

This is not a fixed term contract with a null and void date. Given the policy of all parties regarding the utopia of free GP care for all, why would any new Government abandon this contract when it allows for the expansion of free cover with the total control of cost and fees completely at the Government’s discretion.
We have to work on the basis that this contract is the template for extension of free GP care to all and we must look at it in that light. This is the new GMS contract in disguise. Tweaks in terms of chronic diseases are yet to come.

2. Excluding GP representation from future contract talks?

Section 41 also reaffirms the position that any future talks on a new contract or a review will take place only with the IMO. This continues to exclude a very large number of GPs from having any representation in any talks. If, for any number of plausible reasons, the IMO was unable to engage in or be present at talks, then there would be no GP voice at all. This, from so many points of view, needs to be changed to ‘representative bodies’. It is pitting GP against GP. It is not for the good or betterment of any group. Surely two voices are better than one.  What is required is consensus not exclusion.

3. Giving the Minister for Health free reign to reduce fees at any point?

Clause 17.1:  “The Minister may amend the fees from time to time following consultation.”
Note that the clause refers to ‘consultation’, not ‘negotiation’ or ‘agreement’. Consultation basically means informing. We have seen how effective consultation can be when it comes to slashing fees. The IMO was involved in consultations before each of the four FEMPI cuts but unfortunately, the union was powerless to halt the process.

If you sign this contract you are agreeing to the Minister having total control over your income, the viability of your practice, your quality of life and your standard of living. Can you imagine any other group or individual signing a contract of employment which gives the employer total power to change pay without the employee’s agreement?

Bear in mind in the Definitions & Interpretations section of the contract, points (vi)  & (vii) state that GPs who sign the contract have sole responsibility for meeting the costs of any and all performance and compliance obligations and regulations, as well as data collection and record keeping. It is practically open ended in terms of our responsibility to meet the costs imposed on us by taking on this contract. The Government tells us we are self-employed. Yet they plan to take away all our private income, seek to have total control over our income, and boldly tell us we are responsible for all our own costs in providing the service they want. Is this a Fairytale?

Some may say that the Minister’s power in relation to fees is given to him in The Health Act 2014. That is indeed correct. But it only applies to you if you sign and accept this contract.

4. Giving the HSE the right to assigning patients to your list without agreement?

If you decide to accept this contract and your local colleagues decline, the HSE has the power to assign as many under-6 patients to your list as it desires up to a maximum of 2,200. The only way to stop this happening is to close your list at a lower number, but if you take this option then your list is closed for all patient types, not just U-6s. In effect what this means is that when a lifelong private patient of yours becomes eligible for a GMS or DVC, you cannot accept them onto your list. They will be forced to leave you and sign on with a new GP.
There is a real possibility that a very large number of GPs will not take up this under-6 contract and this power to assign patients has the power to change your practice fundamentally.
Very large numbers of under-6 patients being assigned to any one GP over a short period of time is dangerous and reckless, from both the patient and GP perspective, in terms of health and safety, and wellbeing.
As always, clause 7.1 allows patients to transfer to another GP if they wish with no reason requested, no reason required or desired. But under clause 8.1, the same courtesy is not extended to the GP. To remove a patient from your list or to deny accepting a patient, the GP must provide a reason and that reason will be judged to be appropriate or not by the HSE. Should the HSE find the reason is not valid, you will be forced to include that patient on your list regardless. This is just one of numerous examples in this contract to demonstrate that this is not a level playing pitch. All the odds are stacked against us.

5. Unfair contractual obligations during illness?
According to Sections 11.3 & 11.4, in the event that you become ill, you still retain full responsibility for the proper care of patients on your panel. Can you imagine getting a sudden debilitating illness and in the midst of that ordeal, you must not only find a locum, but the locum must be on the GP Specialist Register. If you are unconscious and being whisked off in an ambulance, the responsibility will fall on your loved ones to find a locum. And as you will contractually retain full responsibility for the care of your patients, you will have sole responsibility for overseeing the quality of care provided by the locum.
This is inhumane and it is just not acceptable in this day and age.

In the event that you are unable to find a locum, the HSE will assign a locum to your practice. However, you will be liable for all of the costs incurred in finding said locum including HSE costs, agency costs, expenses and accommodation if required. Given that there are few locums available at the present time, will this necessitate flying in locums from abroad?

6. Incurring increased out-of-hours demands for decreased fees?
Most of Section 20 is new and different to the terms of the old GMS contract. It is based on the mediated Out-O- Hours Agreement between the IMO and the PCRS which arose because the PCRS was not paying many out-of-hours claims. As free GP care is rolled out, out-of-hours services will become increasingly busy and increasingly expensive. Clause 20.7 states unambiguously that GPs will not receive payment for out-of-hours consultations that are provided merely to facilitate patient preference. Clause 20.3 clearly states that fees will only be provided for consultations which are deemed to be unforeseen and non-routine and which cannot be safely deferred until normal surgery hours. By signing this contract you will be legally contracted to deliver out-of-hours services according to these terms.

7. Being forced to join a primary care team? 
Recitals E Paragraphs 3 & 4, and G & H make it quite clear that GPs who accept this contract MUST work as part of a primary care team. For many, this is a commitment that requires careful consideration.

8. Allowing the HSE to inspect your premises and records at will?
Section 28 permits the HSE to carry out inspections of the premises and your records, and you will be required to facilitate interviews with staff in relation to such inspections.

The Government insists that we are self-employed. If that is the case, these inspection powers are excessive and a step too far, not to mention the potential impact on patient confidentiality and the sacredness of the doctor-patient relationship.

9. Giving the HSE complete control to vary the terms of the agreement as it deems necessary?
Sections 21.1.1 to 21.1.3 confer significant power to the HSE to vary the agreement as they see necessary following “consultation” with the IMO. Note again that this clause does not require agreement in order to “vary the agreement” and simply requires that the GP is notified of this variation in writing at least 30 days in advance.

10. Agreeing to a long list of potential sanctions against GPs.
One of the major problems we have had with the current GMS contract is that, in recent years in particular, the Contract has been torn to pieces by the Government, HSE and PCRS not honouring their side of the agreement. How often has a GP not honoured his or her contractual obligations.

We are now presented with a contract that contains four pages on Suspension, Sanction & Termination procedures with extensive details about how sanctions will be applied to GPs who are deemed not to be fulfilling this new contract. There is not one single word of a sanction against the HSE and PCRS for failing to meet their obligations.

11. Signing a one-sided, unfair contract?
The tone of this document is all wrong. Some of the more ridiculous suggestions in the draft contract of February 2014 have been removed, but unfortunately the tone remains the same. All the obligations are one-sided. No neutral even-minded individual could describe this as a balanced, fair, two-sided document.

The IMO negotiators did not have an enviable task in negotiating this contract. Given the tone and content of the draft contract of February 2014, one can easily identify the mindset of those with whom they had to sit down and negotiate. The negotiators believe this is the best deal that could be achieved at this time. They may well be right. But that does not mean we should accept it if it is not right for general practice in Ireland.
If this is only an interim contract for under-6s care and not a template for the future of general practice, why does it go into such detail and length about the long-term vision for primary health care in Ireland, as set out in the Recitals section. The details on scope of services, obligations, new future initiatives, out-of-hours, inspections, sanctions do not make any sense unless this is the template for a future GMS contract. If we do not stop this train leaving the station, there will be no hope of stopping it in the future.

Even though the party is opposed to the initiative, the Fianna Fails Health Spokesperson has already said that should Fianna Fail be in Government, they will not reverse the under-6s if it has already been accepted and implemented. Other parties will no doubt follow the same principal. We have seen how difficult it is to reverse a decision on free health care. The decision to remove the over-70s cards is a stark example of the difficulties in rowing back on a decision such as this.

The personal same day GP service which we all know and which is so valued by our patients, is about to be taken away. In its place we will have waiting lists, unhappy patients, unhappy burnt-out GPs and recriminations all around. No knight in shining armour is going to come along and save general practice. The only people who can save general practice in Ireland are the GPs of Ireland. That’s you and us. Now is the hour.
We believe that general practice in Ireland as we have known it is in grave danger of dying. The under-6s contract, with its temporary boost and hidden Trojan horses, will only drag out our suffering and inevitable demise. The Government is desperate to get this under-6s deal over the line prior to the General Election. We will never know what we could achieve unless we roundly reject this offer and demand wide-ranging, open and constructive negotiations with all representative bodies for the benefit of all GPs.

Regardless of what anyone says or intimates, no one else can do our jobs or provide the service we do. We are specialists in primary care.

The NAGP will be balloting its members and will accept the majority decision of members on whether to accept or reject this contract.

NAGP National Council
Dr Andrew Jordan, Dr Conor McGee, Dr Emmet Kerin, Dr Keith Swanick, Dr Jim Stacy, Dr Adrian O’ Donovan, Dr Bill Moore, Dr Tadhg O’ Carroll,  Dr Mary O’ Donovan, Dr Daniel Crowley, Dr Yvonne Williams, Dr Anne Marie Vaughan-Carr, Dr John Garvey, Dr Michelle O’ Connor, Dr Claire O’ Driscoll, Dr Chris O’ Rourke, Dr Oliver Lynn,  Dr Mary Flynn, Dr Stephen Murphy, Dr Michael Fay, Dr Diarmuid O’ Connell, Dr Laura Lenihan, Dr Michael McConville