Doctors’ revolution in Limerick

One of my great heroes in journalism was the great John Reed who wrote the definitive book on the Russian Revolution, “Ten days that shook the World” and he did it mostly by being there. He happened to have had the fortune to be in Moscow in October, 1917, and so his eyewitness account of those events has become the standard by which all others are judged.

Limerick isn’t Moscow, and Ireland’s general practitioners aren’t exactly the lumpen proletariat, but last Monday night I got a sense of what John Reed must have felt at the beginning of a revolution. There was a sense that whatever comes next must be radically different from before – a sense that nothing could be the same again.

Now, in a previous existence as Editor of a medical paper I have direct experience of how hard it is to get a bunch of doctors – particularly GPs – into the same room. There are many reasons for this that needn’t detain us here, but the point is that it is extremely tough to get GPs together.

But after a meeting in Cork attracted 250 GPs, I felt compelled to attend the meeting in Limerick this week to see if such a feat were (a) possible and (b) could be duplicated. The meeting, organised by the chief executive of the National Association of General Practitioners (NAGP), Chris Goodey was open to GPs of all colours, including Irish Medical Organisation (IMO) members, but even still, if they could attract 100 GPs, it would have been an excellent turnout – given that Limerick is not as populous as Cork.

In the event 240 GPs showed up with 9 TD’s and senators. To put this in context, there are 2,500-2,700 GPs in the whole country with the biggest numbers based in the Dublin area. It means that nearly every doctor within the catchment area showed up – ten per cent of all Irish GPs.

The TD’s were not about to make political points on behalf of Minister James Reilly at such a meeting. They all promised to ‘listen’, and to take their concerns back to their parties, but mainly their feeling was one of shock – not so much at the issue under discussion, but the sheer political power of such a group gathered in such numbers.

GP’s do have a lot of power. They can’t necessarily tell their patients which way to vote, but they do spend 15 minutes or more with 30 people every day in a one-on-one private and sober conversation. They can tell their patients about their struggles, they can indicate to them that they may not be able to stay in the locality, at election time they can put posters in their reception areas – in short, they can influence a lot of voters.

And these voters are especially motivated on the health issue, because at that very moment, they are not visiting a doctor’s surgery because they are seeking political information. Their chief concern will be their own health or the health of a loved one, and that makes them a committed voter on health issues. They are people who will be prepared to get out there to vote on this current issue which now is their chief concern. And they will listen, as they have before on other serious matters, to what the doctor tells them.

Two-hundred and fifty doctors times 30 patients is a potential for 7,500 voters a day to take a view on health. An unpopular Minster for Health, for example, wouldn’t survive long in that atmosphere. That’s 37,500 people in a week hearing the same message and over time, those sort of numbers add up.

Now, I’m not suggesting here that GP’s are out there every day campaigning in their surgeries for any political party or person or against any political party or person, I’m just suggesting that they have this enormous capability to change political attitudes on health issues.

But they only have this power when they are acting almost unannimously – as they certainly were in Limerick. In the past, it has been possible to divide and conquer GP’s where some of them are willing to go along with government proposals. It puts pressure on the others and after a period of time, they all fall into line.

But in recent years, this power of acting together has almost disappeared with the introduction of the Competition Act which disallows doctors from negotiating with government on the issue of fees but also many other issues.

A High Court case next month will sort out for good whether or not this is in fact legal. The Competition Authority (CA) and the IMO are at loggerheads about whether doctors can negotiate on fees or if they should be granted a derogation from the CA’s strict rules.

Depending on who you talk to, this could go either way. The IMO are desperate to insist that they will win this case and therefore be the only body who can officially negotiate on behalf of doctors. The fledgling NAGP – who need 1,000 members to officially be granted union status to negotiate – are at roughly 900 members, so a victory for the IMO would be a great fillip after two years of scandal and the sharp drop in their finances required to pay off their former CEO.

But even with 900 members, the NAGP are still too big, as it were, to fail to be included in any future agreement between the Department of Health and GP’s. What the turnout in Limerick showed (and we can probably expect similar numbers in future meetings in Galway, Donegal and Dublin) is that GP’s are beginning to assert their power within the health service and are beginning to demand change.

That is a hugely significant development and overall it promises to be a very good one. It is a ridiculous and dystopian idea that you can ‘run’ a health service. Doctors and nurses do the service – everybody else is just padding and support. And the idea that this padding directs and controls everything is inherently a bad, bad idea.

It is perhaps true that doctors (and to a certain extent nurses) allowed this to happen. They haven’t historically had the input they might have had – particularly with issues of policy – and that is why they are in their current state. They have just got on with the job until the conditions and viability of their own jobs proved untenable.

Dr Ed Walsh – the founding President of the University of Limerick also spoke at the meeting and issued a plea to the Department of Health to ‘stop the black propaganda’ emanating from the HSE about how much doctors are paid. He pointed out that last week the HSE chose to release the figures for how much GP practices were paid.  Some practices make up to €750,000. And the implication for the public is that one doctor is getting that money.

In fact, the average GP in Ireland makes €130,000 per year, before taking into account some major expenses such as their mortgage or rent, medical indemnity insurance, admin staff, other doctors and nurses, cleaning, equipment and other expenses associated with running a practice.

Since the FEMPI cuts, isolated sick people have become more isolated. The fee for travelling to see a distant patient has disappeared, so if a doctor has to make a round trip of say 30 miles to see a patient, and he knows this will add an hour to his or her day, this has become even more difficult and happens less often.

This is not because the GP doesn’t want to do it – remember, the vast majority of doctors are highly motivated to look after patients, that’s there raison d’etre – it’s because they know they still have the 30 patients in their surgery who also need to be seen and treated. You can’t do both.

But if you pare a service back to the very bone and run it like a business, it’s the weak and vulnerable who will lose out. The isolated and the very sick. The uneducated, the poor and the disabled suffer the most.

Several doctors told the meeting that their patients who had serious illness and disabilities had lost their medical card because the forms had become more complex and difficult. They hadn’t become less sick. Yet, the HSE will trumpet it from the ramparts that they are ‘controlling costs’ when their real costs are, in fact, real people. It’s all about making it look good on paper, not people.

Most of the TDs present – including local TD Willie O’Dea said that they would not sign the contract as proposed. O’Dea, in his typically colourful way suggested that the contract was more onerous than the Shakesperian one which demanded a ‘pound of flesh’. And, he added, no-one could sign a contract, and he wouldn’t personally sign a contract, that contained a gagging order.

But it’s not about the contract any more – it’s certainly not about the issue of the under 6’s. That issue was defined by one TD at the meeting as ‘taking away cards from the sick, the elderly and the disabled and giving them to healthy young kids who don’t need them’.

No, GP’s saw their strength in numbers at the meeting and the saw the fear in the eyes of their elected representatives. They finally saw that all the bureaucrats, politicians, public servants and strategists can write all the laws they want, but they can’t treat a single person or make a sick person better.

It’s not an unusual idea in the Irish health service that it should be run without consultation with doctors. But it’s an idea whose time has passed. The revolution is happening slowly, but the ancien regime is slowing being dismantled by the political action of GP’s and there’s not much the Minister, the Competition Authority or anyone else can do about that. Sometimes, when the revolution gets going, there is no going back.



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