First, do no harm

There are at least three phrases the Irish people don’t want to hear again after eating the humble pie of an economic collapse.

Those post-prandial flourishes – “We are where we are”, “legacy issues” and “the actions of a previous government” seem like reasonable excuses, but not when the government seems hell-bent on creating the type of problems now that will come back to haunt us in the future.

Such is the case with general practice and primary care. If we continue as we are, we will store up major problems in the one part of the health service that works efficiently, economically and effectively, and we are doomed to hear to some future government use the above troika of excuses as they try to mitigate problems of their own (or their predecessors’) creation.

General practice deals with 95% of patient interaction in the health service. General Practitioners co-ordinate the care of patients right through the system – from securing medical cards for needy and sick people to their aftercare when they are discharged from hospital.

They do this on less than 3% of the overall health budget. Despite having the lowest budget in the OECD for general practice, survey after survey shows that Irish people are very happy with their local doctor. And given the lack of funding, we have an excellent same-day service comparatively.

But as the town hall meetings around the country have shown – culminating in 500 doctors meeting in the Double Tree Hotel in Dublin last week – we are in danger of destroying that service, and here’s why.

It takes 10-14 years to train a GP and even more years before they become embedded in a community. Most of these highly-qualified people also have a vocational aspect to what they do. They eschew the massive levels of management that are commonplace in other parts of the health service and in many cases they deliver services – such as blood tests and Warfarin clinics – for which they are not paid. They treat the patient with the disease, not the disease the patient has.

In the US, where family doctors are rarer and most people are treated by a specialist, morbidity rates are much higher. The specialist treats the one problem, but has no responsibility for the overall good of the patient. That’s one of the reasons why the US spends a lot of money on health but still has one of the worst systems in terms of health and wellness.

Now, it is one thing to introduce a cut in pay to a civil servant who receives a salary. Such a person will still have a pension, and a secure job. They are not – as all GPs are – a self-employed businessperson with a staff and a lot of costs (which incidentally have not gone down) and who may go out of business.

GPs are paid per GMS patient per year. Out of that they have to pay for their rent or mortgage, medical insurance, staff and all the other costs that come with providing a service. The real problem here is that since the cuts have been introduced, it has left little money over to pay themselves a salary. So some have not had a cut to their salaries – they have had them wiped out.

That is obviously a non-sustainable situation, but though 100 practices are now close to insolvency, and over 1,000 highly-trained GPs have left the country, this problem won’t really manifest itself for a few more years.

The problem is there now, but it is not noticeable to the general public. People won’t notice GPs until their local GP is not there, or they have to wait a week for an appointment, or until their care drops below an acceptable standard.

All of this is avoidable by taking action now.

GPs have hung on despite the cuts because, in many cases, they have invested heavily in providing their practices and despite the lure of better money abroad, and much more efficient health systems that allow them a work/life balance, they want to do the work in Ireland that they were trained to do.

We train 157 GPs each year and this year, for the first year, we just about got enough applicants. Most of those will emigrate and our huge investment in them will be lost. They will not come back to a dysfunctional system that prevents them from making a living. But that will be our loss, not theirs.

The government has limitations on what it can take back from employees, but when it comes to running a service with self-employed businesspeople, it is, as you might expect, as successful as any government is when it gets involved in business.

It has gutted general practice, and the damage is continuing every day.

GPs have struggled on, but the mood is changing now and many are deciding to go abroad or retire early. We have about 50% of the GPs of the average OECD country and what are we doing? We are driving some of our most talented and dedicated people out of the country, having spent a fortune training them to be the best and the brightest.

What’s so extraordinary, is that is it government policy to move many services into primary care which is slightly different from general practice, but as it stands, at the first point of contact, we don’t have a primary care system, we have a general practice system.

The reason we need and want to do this is that treating patients in general practice is much, much cheaper than treating them in hospitals, because small businesses are acutely aware of costs, and big State institutions are voracious consumers of cash.

At the town hall meetings, the National Association of General Practitioners has called for 1% of the health budget to be transferred to general practice per year until we reach the UK standard of 8%. This strategic move could be the makings of the health service, allowing more work to be done with less money.

But the money isn’t following either the patient or the government’s own logic. It is destroying the one part of the health service that works. It will take time before this disaster has become one that affects people, and when it does, be prepared to hear about how it was someone else’s fault, it’s a legacy issue and that we are where we are.

We don’t have to go down this road. The first rule in medicine is to ‘do no harm’. Sadly, when it pertains to our health service and Minister, they can’t even follow that injunction.

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