Medical Matters: Rural general practice cannot be allowed to die on its feet

Traditional general practice is dying in the Irish countryside. Practice after practice is falling vacant. Many GPs are holding on only out of a sense of duty and loyalty to their patients, and this workforce is getting older. When GPs retire or cannot afford to carry on, there is nobody to replace them. Approximately 25 GP positions are vacant. This is because they are unable to survive financially.

Why should a practice that performed an essential service and creates employment cease to be viable? There are many reasons. Fempi (Financial Emergency Provisions in the Public Interest) cuts have hit general practice exorbitantly, reducing the income of a practice by about 38 per cent. Then the distance code was abolished. This was a fair system that meant the farther a patient was from a treatment centre, the more money the practice was allocated for travel. So at least if the doctor spent an hour in the car on a house call, the cost of the petrol was covered.

As if that wasn’t enough, the rural practice allowance, which was allocated to an area considered to be far from services, is being contested in many areas by the HSE, and is not renewed when a practice becomes vacant. This is, presumably, done to save money even though the circumstances in the area have not changed.

The allowance had recognised the fact that an area that is remote and large has to provide services that are provided by several agencies in a city. It gives the practice a modest stipend and some extra finances for staff and holiday relief. The savings to the HSE are derisory. In reality, there is no saving at all.

Research has shown that if you spend a little on traditional primary care, you will save a lot in secondary and tertiary care. For example, a country GP will drive miles to see an elderly person with pneumonia and then call several times over the next week. If that person had ended up in hospital, it would have cost the State thousands of euro.

Rural patients tend to include a high proportion of old, sick and disadvantaged people. In many communities the family doctor is the last service standing; the post office, Garda station and village school are closed and now traditional medical practices are closing as well. Communities that evolved over decades and centuries are fading away.

The HSE seems to favour giant primary care centres in big towns. It is as if they are closing local shops and forcing people to travel miles to the supermarket while ignoring the fact that the supermarket has yet to be built. Few GPs have the appetite or the resources to invest in these potential white elephants.

There is no policy to attract new graduates to rural practice. I recently addressed a class of newly graduated GPs and not one wanted to go abroad. Many wanted to stay in Ireland. They would gladly embrace the rural way of life if they thought that they could make a living out of it. But because these graduates are forced to go abroad there is a dearth of locums, which makes single-handed practice even more untenable. Would it be so bad to encourage rural practice allowances and make employment in traditional general practice attractive? The same sum would be spent improving a road from one dying town to another without discussion. Cars seem to be more important than people.

Many years ago the late John Healy wrote about the destruction of rural communities in this paper. His columns formed the basis of a highly regarded book called No One Shouted Stop!. The Irish College of General Practitioners, IMO, National Association of GPs and Rural Doctors Association are all shouting "Stop". If the degradation of rural practice continues, babies will be born on the side of the road, people who have heart attacks will die waiting for ambulances, and pensioners who have strokes will not be caught in time and will be left permanently and needlessly incapacitated. People who have lived all their lives in the countryside will be forced to move to nursing homes in the cities.

The message from the Government and the HSE is clear: the life of a person in a rural community is less valuable than the life of a city dweller.

Dr Pat Harrold is a GP in Nenagh, Co Tipperary.

Dr Muiris Houston is on leave.