General Practice in Crisis


You may have noticed a lot of attention in the media recently about the fact that over 90% of Irish GPs have said they will not sign up to the current draft of proposed 'free' GP care to Under-6s.

The document that is causing such concern among GPs is intended to enable the provision of 'Free' GP care to under 6's, as promised by Minister Reilly out of the blue some months back without so much as a word of consultation with the GPs who are supposed to provide this care and with only a passing reference to the resources required.

Much will be made in the coming weeks of our refusal to sign as the Government try to dig their way out of this latest fiasco.

GPs will be painted as greedy, money-grabbing, uncaring individuals who don't want to look after the countries children. Inflated details of the monies paid to GPs will be leaked to the media (as they are every year) in a bid to turn public opinion against us.

It is only fair that GPs get a chance to present our side of this situation in advance of the Government spin machine....

You may have noticed a lot of attention in the media recently about the fact that over 90% of Irish GPs have said they will not sign up to the current draft of proposed 'free' GP care to Under-6s.

The document that is causing such concern among GPs is intended to enable the provision of 'Free' GP care to under 6's, as promised by Minister Reilly out of the blue some months back without so much as a word of consultation with the GPs who are supposed to provide this care and with only a passing reference to the resources required.

Much will be made in the coming weeks of our refusal to sign as the Government try to dig their way out of this latest fiasco.

GPs will be painted as greedy, money-grabbing, uncaring individuals who don't want to look after the countries children. Inflated details of the monies paid to GPs will be leaked to the media (as they are every year) in a bid to turn public opinion against us.

It is only fair that GPs get a chance to present our side of this situation in advance of the Government spin machine....

Please don't assume that GPs are refusing to sign this contract  because we don't want universal healthcare. Most GPs do - we just don't want a nonsensical system that won't work and will result in a worse system than currently exists. Such a radical change to the current system requires a lot of planning and resourcing - in a different way to how GP care is currently delivered.

The full text of the draft contract is here:  Draft Contract

Below is the submission Dr Murphy sent to the HSE national contracts office as part of the 'consultation process' this week. Unfortunately, the HSE didn't consult with any GPs or GP representative bodies before writing this 40-page draft - which is why it's so poorly thought out and unworkable. They need to go back to the drawing board.

General Practice is in crisis after a series of harsh cuts to funding and many surgeries are on the brink of closing down. Politicians are not aware of how General Practice works, but are learning fast since this contract appeared.

If you want to continue to have access to an excellent GP service, whether you want to pay for it or not, please lobby your local TDs to protect what we have before it's too late.

Who would you prefer to look after your children?

Your family doctor or the HSE Management responsible for the shocking state of our hospitals?

The choice is about to be made for you....

 

Dear HSE Contracts Office

Re: Proposed draft contract for free GP care to Under-6s

As you are probably aware, two recent large surveys of GPs in Ireland in recent weeks have shown that over 90% of Irish GPs are not prepared to sign the contract you circulated for free GP care to Under-6's. This is an unprecedented move by GPs showing that you have clearly created something that is completely unworkable. GPs have absorbed cut after cut, but cannot take any more attacks on our specialty, nor can we agree to a contract that is unworkable. I am one of the 91-98% of GPs who will not sign this contract. Here are some of my reasons:

1. This new contract is completely different to the current one, with a significantly altered, increased workload - both clinically and administratively. It cannot be delivered in the current infrastructure, where GPs are already responsible for all of the overheads and staff costs of running a business. This is the case regardless of what fee structure you propose. It requires far more resourcing of General Practice in terms of medical and support staff, and probably a few years of negotiating with our representative bodies who can advise what will work. Our current contract is for acute care. You want us to now provide without limitation, acute care, prevention, health surveillance, chronic care, diagnosis and management of all conditions, phlebotomy, vaccination, palliative care and treatment of minor injuries etc - but all within the existing infrastructure?! And you haven't mentioned how this will be funded and who will deliver it.

2. I am quite sure that my solicitor as well as my financial advisor would advise against me signing such a prohibitive contract - eg major data protection and confidentiality issues, complying with lots of unspecified protocols and guidelines without knowing what's involved or why, reporting to the HSE on EVERY consultation - a ridiculous waste of resources, proving emergency consults were necessary - (if a patient thinks they needed emergency treatment how can the HSE argue they didn't), providing HSE with annual registers, signing up to a 5-year contract subject to performance review - (we comply with the Medical Council standards which are appropriate and sufficient).

I will defer paying my own advisors for forensic analysis at the moment as I am in no doubt that my business can't support the level of risk and extra pressure involved.

3. General Practice is one of the only parts of the Irish healthcare system that works, solving 90% of the country's healthcare problems with just 2% of the budget - doing 24 million consultations per year without waiting lists. What you are proposing will stop it working. It works because GPs have autonomy and take pride in providing a same day service to all patients regardless of their ability to pay. We manage a two-tier system without discriminating against either side. The majority of GPs would be strongly in favour of a system where patients don't have to pay at point of care, or at least that they wouldn't have a financial barrier to seeking help when needed. However, this can't happen with a wave of a hand or without an evidence-based plan for appropriate resourcing. What you propose will negatively alter the clinical to administrative burden leading to levels of inefficiency on a par with Irish hospitals. I do not want to be a part of this process.

4. In the very unlikely event that GPs signed up to this contract, I foresee that the amount of extra administrative, clinical and screening workload proposed would mean that we would have to greatly reduce the amount of time we are available to deal with patients who are sick and want to be seen on the day (which is what we currently devote most of our time to). This means creating a waiting list for patients signed up on the new contract, as we have to split our time according to our business model - ensuring we see enough patients who bring in revenue to allow staff and bills to be paid. Continuing the current illness capitation model is not viable for the amount of extra work proposed.

5. So when patients phone wanting an appointment on the day because they feel sick, we could offer them an appointment 5 days later as we are too busy doing 1-hour 'Healthy Ireland' checks on perfectly well 4-year old children, and writing up pointless reports (as suggested in your draft contract). Waiting lists will grow and consultation times reduce, similar to the 'free' NHS system in the UK. However, we can direct sick patients to Accident and Emergency Departments if they feel they can't wait 5 days, as that service is also 'free'. No letter needed, they can just turn up. Of the 24 million consultations per year we currently do, we may end up sending an extra few million patients to A/E as we are too busy doing extra paperwork and fixing flaking paint so haven't time to see patients. The hospital system will collapse. As you are aware, it is already in crisis.

The HSE will be responsible for this catastrophe, not GPs.

6. Similarly, you are missing opportunities to reduce the burden on A/E and other hospital departments by not resourcing General Practice to do procedures in our surgeries instead of hospitals. For example, it has not been financially viable in recent years to provide a suturing service or other minor surgery procedures to medical card holders, due to the much cut and now insulting fee for this of €24.80 before tax. The cost of sutures, suture kits, dressing packs and sterile gloves alone eats up most of this fee. But a GP skilled in this area and appropriately indemnified is also needed, for about 30 minutes, along with a heated insured building and a nurse to assist, all of this to be available on an emergency basis when someone suffers a laceration. It costs on average approximately €200/hour to provide routine services in our surgery, more for extra services. We happily provide a suturing and minor surgery service for patients who provide sufficient revenue to allow us provide the service, this no longer includes medical card patients as it is unsafe to try to suture someone in the 3-4 minutes your fee allows. How much do Consultants charge to do this? €160 for a consultation and another few hundred to do the procedure? I would estimate that when we send these patients to A/E it costs the state a lot more, perhaps €1-2000/hour to suture a patient's laceration in the 'free' hospital system? Why are you pushing us to refer more to hospital due to FEMPI cuts? Is it not Minister Reillys stated aim of the future delivery of healthcare services that this be provided at the lowest level of complexity, not the highest?

7. The other side of this dilemma is that you will be responsible for creating a 2-tier or 3-tier system in General Practice which was never present before. To run a viable business, we must allow enough appointments per day to cover the costs, so if we get more income from private patients this is what will take priority. GPs are excellent at running General Practice. Politicians and HSE management have no idea how it works. It is essential you allow our representative bodies to negotiate a healthcare plan that will work and abandon the current dictatorial musings which will clearly fail. It is unlikely to cost more, but it will work. It will take years to plan.

8. The draft contract insists that GPs will be part of Primary Care Teams. This is only possible in a minority of cases, and will never work in my area. An attempt was made to put about 24 GPs in Galway city centre into a team as no other solution was found. This clearly will never work and I will not sign a contract which pretends that it will.

9. Perhaps you have not thought about the impact on Out-of-Hours GP services? At present there are a variety of arrangements around the country of co-operatives, rotas etc which rely on a group of GPs agreeing to provide a particular service. What happens if a few GPs sign this contract and agree to provide 24-hour care to Under-6s, but their colleagues in the same rota do not sign up and therefore will charge any patients they see in the evening or weekend? Should rotas exclude GPs who have agreed to take on this contract and extra commitments? Do you have alternative plans to hire other doctors out of hours to provide 24-hour cover, or is the care you propose on a 40-hour week basis only?

10. I am not in favour of a corporatised insurance-based UHI system which you are heading towards, as it has to include a significant profit margin for insurance companies, at the expense of patients. This will ultimately cost the taxpayer more. If you negotiated longer with GPs about how to appropriately expand primary Care Services, you would achieve a better service at lower cost. Families may end up paying €4-5000 per year to insurance companies for 'free' care, then regret they didn't remain in the pay as you go current system with better quality of care and same day access to GPs. The Aviva stadium wasn't 'free', someone has to pay.

11. Having set up in practice 5 years ago, I am struggling to earn a secure and reasonable living on the current system. My practice may earn about €150,000/year from the HSE and more from private patients, yet despite working 40-60 hours per week I end up with about 10-20% of this turnover. The costs are huge. The HSE are clearly under some illusion that GPs earn lots of money, the reverse is true and the situation is worse for my generation of GPs who didn't get to accumulate money during the boom years when the contract paid reasonably well. I cannot afford to take on a new level of risk which could send me out of business and leave me unemployed - in a country where you admit there is a shortage of qualified GPs. Most recently qualified GPs will not set up in practice as it is not viable. Emigration is becoming more and more attractive.

12. Clearly the politicians who came up with this draft contract can't even agree on whether a fee will apply to the 'free' care. Minister Reilly says absolutely not, Junior Minister White says a €5 - €10 fee may apply, but certainly not to the new under-6s. Does he mean it applies to the existing poorer under-6s but not the new rich kids?! This beggars belief and is another reason to mistrust the whole process.So much public money has been wasted on producing a huge useless document that will go nowhere.

13. Fundamentally I do not trust this Government in their commitment to patients. Those in great need of a medical card are losing them under probity and cost-cutting, while an easy group (young children) have been targeted to try to give the illusion that you could achieve universal healthcare for all by 2016. Clearly there is not a hope of this happening. There is no evidence for giving young healthy wealthy children free care at the expense of those who have greater need.

This draft contract was presented publicly without consultation, discussion or negotiation with General Practitioners, who are the only group able to deliver the care. I echo other GPs in calling for it to be publicly withdrawn. If General Practice is not to collapse completely over the next few months, it is now imperative that government/HSE formally sits down with GPs through their representative organisations and collectively agree a new contract which properly reflects 21st century medical practice.

Yours Sincerely

Dr Sinead Murphy MB BCh BAO MICGP MCN 22649

Comments

  • Avatar-2
    Joe Gallagher said:
    Wonderful piece covering all aspects of the shambles, charade and incompetence we are enduring. Shining a light like this is to your credit.
    Created: 15/04/2014

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