Prognosis not good for GP services

For the first time in his 32 years in general practice, Dr Conor O’Neill is in “big trouble” financially and he fears that he could be one of the first of the Irish GPs forced to close their doors as a result of funding cutbacks.The National Association of General Practitioners (NAGP) has warned that 8 per cent of practices in Ireland will no longer be able to afford to operate and face closure, possibly within a year.

While the plight of the junior doctors has been well publicised, with many young doctors leaving the country rather than continue to put up with excessively long hours and dangerous working conditions, the crisis in general practice has been bubbling away quietly beneath the surface.

However, the NAGP’s launch yesterday of a nationwide patient awareness campaign entitled General Practice in Crisis, highlights the detrimental impact cuts made over the last three years under the Financial Emergency Measures in the Public Interest Act 2009 (FEMPI) are having on the ground.

Over the past three years, €160 million has been taken from general practice, equating to an average of a 33 per cent reduction of funding in income to individual practices, according to the NAGP. As a result of the latest round of cuts announced in July, many GPs say their services are now at breaking pointing and they predict serious difficulties in coping with the day-to-day running of their practices, particularly in the autumn/winter.

There are 2,728 GPs registered with the Irish Medical Council, with females representing 46.3 per cent of GPs overall, according to the latest figures.

Reality of cuts on the ground
As a result of the cuts O'Neill, who runs a sole practice in Waterford, has no money to buy new medical equipment, he may be forced to stop house calls to his most vulnerable patients and he has to personally transport bloods to the local hospital during his lunch hour because he can no longer afford a courier.

He employs a full-time secretary and more than 90 per cent of his patients are GMS patients. His gross income has been reducing since 2009 while at the same time he has seen a huge reduction in private patients, but his overheads – medical indemnity insurance, heat, electricity, staff costs etc – have gone up.

"People assume GPs are all very well off; they have no idea what's going on. I have two children still at college and have come to the point where I have very little left over after I pay my overheads. I will be one of the first 8 per cent out the door because I won't be able to afford to keep my practice open. I will be left with no choice but to notify the HSE that I can't afford to practise anymore because I can't run my practice and earn a living. Until such a time as my outgoings are greater than my incomings, I will keep going but when that day comes, which may be very shortly, I will have to quit and I certainly won't be the only one."

O’Neill, who is 62, says he has to consider the impact of this pressure on his own health. He points out that there are GPs in this country taking their own lives because of the stress they are under and the saddest part of it all is that until now, general practice was the only part of the Irish healthcare system that worked well.

"We are in a major crisis here and it seems to me that the Department of Health and the HSE do not give a damn. This crisis is only going to get worse, I can guarantee. Patients are going to die as result of this through no fault of the GPs. They (the HSE and Department of Health) have got a lot to answer for."

Bedbound patients
O'Neill explains that he has quite a number of patients who are bedbound and have not set foot in his practice for eight years. These are people with MS or dementia, who have had strokes or amputations and who tend to get really sick in winter. If he can no longer visit them in their homes, it will cost the taxpayer thousands for them to be treated in hospital, which is where they will inevitably end up.

“This morning a woman came into my office crying because her father had his medical card taken from him. He had a stroke eight years ago and she has cared for him 24/7 since. Another 80-year-old lady had her medical card taken off her because she was €4 over her means.

“Every day, I get people like these coming into me under severe stress. It breaks my heart to see their crying, they are so scared they won’t be able to afford their medication. It’s soul destroying.”

Dr Afric Boylan works in a rural practice at Johnstown Bridge, Enfield, Co Meath, where about 60 per cent of patients are medical-card holders. Five years ago, 60 per cent of her patients were private.

“There is very real concern about the financial viability of our practice. The principal GP, who has been here for years, has warned us that if things continue as they are, jobs will have to go. The practice might close because it’s not able to support itself. There are more FEMPI cuts coming in September and more planned for next year and we are just treading water at the moment.”

They are at full capacity now during the summer and are concerned about how vulnerable patients are going to cope without house calls in winter, warning that they will end up in hospital or worse because they are not seen on time.

She says she and many of her fellow GPs have seen a significant increase in psychological medicine as a direct effect of the economic downturn. These are patients with higher medical needs, she explains, who cannot be shoehorned into 15-minute appointments.

A system that works
"The Irish primary care system and general practice as it exists in this country does work pretty well. If you need to see a GP on a day, it's likely you will be able to. I would hate to see patients having to wait two weeks to see a doctor unless they were super-sick, as happens with the NHS in the UK. The system we have is good if properly resourced, and the satisfaction rate with general practice in Ireland is quite high."

While many of her contemporaries in medical training are leaving Ireland by the day, Boylan, who is 33, hopes she will not have to emigrate. She spent over 11 years training to be a GP but says that, like many of her fellow GPs, she feels very demoralised and distanced from the HSE and Department of Health.

“I am at the beginning of my career in general practice. I love my job and love living in Ireland. I don’t want to live anywhere else but I have a young family and I need to make a fair living. I want to stay and try to make things better here through the NAGP, but I do worry that if things don’t improve, it will not be viable to stay in Ireland. I hope that will not be the case. The Irish taxpayers have invested 10 years of money in training us, they deserve to keep us.”

The NAGP is calling on members of the public to act now and sign a petition at nagp.ie, to contact their public representative immediately and voice their objection to these cutbacks.

Dr Conor McGee, president of the NAGP, says: “Our association seeks to highlight the impact the cuts will have on the community. The recent 7.5 per cent cut in GPs’ fees will result in 8 per cent of practices in Ireland facing major financial difficulties, as GPs will no longer be able to afford to run their practices. This could result in the closure of over 120 general practices around the country. This nationwide campaign hopes to reinforce our total commitment to our patients and the service that we offer them.”

The Irish Medical Organisation (IMO) points out that GPs in Ireland perform in excess of 18 million patient consultations on average per year. with over 70 per cent of patients needs being dealt with without the need for referral. Yet the GP budget accounts for only 2 per cent of the overall health budget.

Shirley Coulter, assistant director of industrial relations at the IMO, says the impact of the latest FEMPI cuts is already being felt by both GPs and patients: for the first time in Ireland, waiting lists to see a GP were being reported, along with increased attendance at GP out-of-hours services.

The IMO will be going to the High Court in early 2014 to defend the right of GPs to be fully represented by their trade union in negotiations with Government.

Meanwhile, the Irish College of General Practioners has written to Minister for Health James Reilly expressing serious concerns for its members and for patients following the latest round of FEMPI cuts.

A spokesman for the Department of Health said the recent reduction in fees paid to GPs and to pharmacists had been decided after a consultation process and considerable analysis by the Department in order to make certain that the reductions were proportionate and fair.

These reductions would save an estimated €16 million this year and €38 million in a full year, he said.