We got an almost perfect illustration the week before last of how and why the health service is so dysfunctional, and how the bust and boom cycle aggravates many of the problems it faces. It’s almost certain that these factors – aggravated and intensified for political reasons – have caused deaths among the Irish population that would otherwise not have happened, so it is an extremely serious and important issue.
The event that demonstrated this fact so effectively was the protest at the Daíl by the National Association of General Practitioners, (NAGP) and the subsequent response from the Minister for Health, Leo Varadkar – which presumably will be his actual response in the upcoming Budget submissions for his Department.
About 300 GPs gathered outside Buswells Hotel in Dublin having traveled by bus from all over the country. They were protesting at the FEMPI cuts (Financial Emergency Measures in the Public Interest) to general practice, which have seen cuts of 40% to the resources provided to GPs to run their independent businesses, which the State contracts to provide a primary care service.
The GPs were there to make the following points: that this cut is disproportionate to any other cut in any other area of austerity; that these cuts, because they are not salary cuts per se, but an overall cut in resources, mean that either GPs take massive cuts in take-home pay or simply cut services, which affects patient care; that many GP practices are now insolvent and may close; that young and middle-aged GPs are emigrating in great numbers, and this will take years to reverse and will create a crisis for the future; and that in any case, the government’s own stated policy is to move more healthcare to primary care where it is cheaper and will result in an overall reduction in costs to the Exchequer.
We can sympathise with the GPs or not – the crucial point here is that austerity and the policies of ‘bust’ are already beginning to cost lives. Ninety-eight per cent of all consultations in the health service happen at primary care level. It’s one of the best parts of the service with almost all patients being seen on a same-day basis, huge levels of public approval, and all this is done on a fraction of the overall health budget. So whether we care about the GPs or not, the case they make on behalf of their patients is a powerful one.
But it’s not even as simple or cut and dried as that. Government policy – in order to deal with the spiralling costs in health – need to make things more cost effective. It is universally agreed that the best way to do this is to move more work from expensive hospitals to local primary care centres. But when we look at other countries who have successfully done this we find an anomaly. In Holland, for example, which we are often told to look to as a good model, they spend 20% of their health budget on primary care – roughly 10% on general practice and another 10% on more general primary care facilities and staff. Here, we spend 2.3%. In the NHS in the UK, the figure is around 9%.
So there is a serious shortfall in what we need to spend in primary care here if we want to follow the government’s own policy to reduce costs – or at least keep them at an acceptable level.
Now, depending on your political perspective, you might or might not agree with giving more money to the health service. But I think everybody could agree that if the health service could produce better results with the same money, we would all welcome that.
The doctors who gathered outside the Dail would meet most people’s standards therefore for coming up with a positive and workable idea – not to increase the health spend, but simply, on a graduated basis, to move some of the massive spend which constitutes 97% of the money allocated to health to general practice on a year-by-year basis.
They proposed a 2% re-allocation this year followed by 1% in future years. This money would allow for a lot more services in primary care thus relieving Emergency Departments and hospitals in general. It would save money. It would guarantee that GPs were brought into the system to do even more work and halt the growing tide of GPs leaving this country.
But the response of the Minister for Health indicated that none of this would be done (despite the fact that this is what needs to be done according to the government’s own policy and analysis) and the two reasons cited by the Minister in his statement (he could hardly ignore the fact that he had 300 doctors protesting outside his office) were that there were more GPs in the GMS scheme than ever and the payments to the GMS scheme were greater than ever.
In his statement he noted that there were 2,416 GPs contracted to the HSE in April 2014 as opposed to 2,258 in 2010, and that payments to GPs under the GMS contract had risen to €447 million in 2013, compared to €438 million in 2011. Technically, this is true, but, of course, Mr Varadkar left out the inconvenient facts about why this is true.
Firstly, there was an extension of eligibility for getting a GMS contract a few years ago and it allowed a lot of young GPs to acquire a GMS list where before they would have worked, perhaps for several years for someone else, while building towards setting up their own practice. And yes, this brought 168 more doctors into a position where they could receive payments from the HSE, but didn’t actually add any doctors to the system.
The second canard is that payments are up. This is also, essentially, true. There is another €9 million being paid out for treating medical card holders – albeit shared with more doctors – but medical card numbers have almost doubled in that time, and, if another ‘policy’ decision is carried through, there will even more medical card holders added to the system under the free care for the under 6’s scheme and perhaps other groups of people with chronic conditions.
Now, even if we ignore the increase in GP numbers, I think most of us would accept that a doubling of workload for a 2% increase in money is not an actual increase in money but a decrease. When you add in the fact that there are 7% more doctors to share in this bonanza, it certainly is.
So there are two possibilities as to why Minister Varadkar responded in this disingenuous and obfuscating way. The first, which hardly bears thinking about, is that this is what he really thinks. That despite all the data and research showing that GPs are leaving the country in droves, that patient care is affected, that general practice is in crisis he can point to a few meaningless statistics and that covers the issue for today.
No problem here.
I wouldn’t insult the Minister with that analysis. It would be impossible for someone with his knowledge and education to be that insensate to the current reality of general practice in Ireland – especially given that he is a GP himself.
So the only other conclusion is that the Minister is aware of the problems, but (and this is backed up by his unwillingness to even have a conversation with the doctors) is unwilling to do anything about it because he is held in a vice-grip by his cabinet colleagues who want nothing from health other than for it to remain within budget.
But, you’d say, this will not affect the overall budget. That’s true. But a re-allocation or resources in one area might lead to calls for re-allocations in others. (If health is important, isn’t education just as important?)
So the Minister has to stay at arm’s length and not engage in a conversation with the doctors who would then be able to nail him down on the facts and he would be forced to either agree (again, it’s his own policy) or look like a fool.
He can, of course, talk to the IMO who have a large consultant membership, because they will be less pushy in demanding that money follows the patient into primary care, because it would take some money (albeit a relatively small amount) from their hospital fiefdoms.
So he issues a statement which contradicts the GP’s claims – even though he knows it is disinformation and distortion – and hope the issue moves along for another day. It keeps the rest of government happy because they can point to the books and claim they achieving things, which they are to a certain extent, on paper.
But patients’ lives are not improved by arcane statistics on a balance sheet. Boom and bust policies are hugely destructive in health as they are elsewhere, and in general practice they are destroying the one part of the health service that was working. But let’s not kid ourselves that this is happening because of a lack of money. It is a lack of willingness or drive to do something in health, as opposed to being completely focussed on finances and allowing nothing to happen that might threaten the consensus of austerity.
In a game where good, practical ideas are merely high cards – no matter how many of them you hold – austerity is the trump card that beats everything. And that card may destroy the very thing that we are hoping to achieve by being fiscally prudent – ie. better services for Irish people. But to Leo, people are the wood and the policies of austerity are the only trees he sees.