GP’s unable to make a living in rural Ireland

There has been a Dr Casey working as a GP in Clifden since 1916. When the current Dr Casey’s father, Dr Michael Casey took over in the 1940s, he replaced another Dr Casey (no relation) and when he retired in 1974, his son, Dr John Casey took over.

But it’s unlikely that a Dr Casey will have been the local doctor in Clifden for a hundred years in 2016, despite the fact that Dr Casey’s son, (also John) has qualified as a GP and works in the practice with him.

Dr Casey – who employs 7-8 staff – says that his practice can’t survive much longer than another couple of months. He is similar to GPs up and down the country, particularly in rural areas who find that they have not suffered a reduction in income, they have been subject to a complete loss of income.

Many people don’t realise that their local doctor didn’t just take a cut like everyone else who is directly or indirectly employed by the government. For many, they were left without any income at all, because, one presumes, the judgement was that GPs are so entrenched in their communities, they wouldn’t leave under any circumstances. But no-one can work day after day, week after week for nothing.

I met Dr Casey in his surgery this week to talk about how the FEMPI cuts are driving him out of business. His surgery is in a small house just outside the town – an almost complete anonymous building with no signs outside. I ask him about the lack of signage.

“We put up some signs recently but Galway County Council told us to take them down. We didn’t have planning permission. One morning we have four cardiac events here – the last one being very serious. We have two local ambulances so they were used. But for the fourth and most serious case, the ambulance had to come from Castlebar. It spent 20 minutes driving around town looking for us – all during that ‘golden hour’.”

Dealing with centralised bureaucracy and its frustrations are simply part of being a country doctor, but the ‘golden hour’ referred to by Dr Casey is a vital concept for those who live in isolated communities. Having a high-quality GP in the area, someone who is available 24/7 is the difference between life and death in many emergency cases.

The claim on the recent Prime Time programme by the head of the National Ambulance Service, Martin Dunne, that ‘we have the best ambulance service in the world with the best uniforms’ was shown on that programme to be untrue. The ambulance service has revised downwards its HIQA-set goals in terms of reaching people within a reasonable time, most of the time. In this situation, the GP assumes an even greater and more important role of being a potential first responder.

Many of the serious health incidents that happen to people need not cause lifelong debilitating illnesses if they are treated early enough. Car accidents, heart attacks and strokes are all serious life events that may cause injury and death, but in many cases, the most serious damage can be limited if the person in question gets to see a doctor within an hour, and, of course, the sooner the better.

The greatest and most talented of hospital doctors can only put Humpty Dumpty back together again if the person has had their condition stabilised within that first hour. And that is one of the great advantages of having an excellent primary care service. But Dr Casey doesn’t think he can stay in business for more than another few months. Why?

“When the cuts came in I would have been happy to take a 10% salary cut or even 20%. But what they have cut is my practice income, which employs eight people. After I pay my staff and out-goings, there is nothing left. I got paid nothing this month – like most months in the last 12 – and I have outstanding bills which I can’t pay. It’s financed out of a large overdraft and if the bank were to call it in…”

He leaves the sentence unfinished. He has lost several staff members already and has been unable to replace vital equipment. He has written to Minister James Reilly outlining the problems, but his letters go unanswered.

“From 7.30 this morning we were treating people here. We dealt with 70 patients. Conservatively, we could have referred 40 of them to Galway Hospital where they would join a long line of people. We do Warfarin Clinics, blood pressure clinics – all sorts of services that we don’t officially have to provide. But if we don’t provide them, our patients suffer by having to travel and having to wait. I fear for my patients and the whole health system here if we weren’t here to provide those services.”

Part of the reason why rural GPs are in this situation is that the FEMPI cuts (Financial Measures in the Public Interest) disproportionately hit rural doctors more. In an area like Clifden, a large number of patients are elderly and unable to travel to the surgery. The FEMPI cuts took away the fee for travelling long distances to patients.

Now, the fee was probably a little generous, but it was used in many practices to subsidise other patients. And this is the way in which Ireland has developed such a stellar GP service. Being a GP is a vocational pursuit as much as it is a job. A doctor doesn’t start a practice in Clifden with the idea of moving upwards and onwards to something more lucrative. When you set up a practice like that, in a place like that, you expect to be buried there.

Equally, that level of commitment and knowledge of an area and its inhabitants is an enormous resource. We set off on a house call to see a bit of the area. The plan is to visit a 94-year-old woman.

On the way, however, Casey is stopped by a traffic light and chats with two men outside a pub where they are having a cigarette. He jokes with them about the cigarettes and makes a motion of drinking which they (in sign language) deny, it being fairly early in the day. He laughs at their denials and gently encourages them to take care of themselves.

This presence of a local doctor who knows the community is better than any TV campaign to encourage better health. Doctors often are told things that people would never tell their priest. They carry not just a mine of medical information and knowledge, but a knowledge of their communities and their peccadilloes.

“When I came here first in 1974 we had just two clinics. The rest of the time was on the road visiting patients. Now, we have a clinic every day, but there is still a cohort of patients that need to be visited at home. It costs me money now every time I do it,” he says.

But there is no alternative. And that is what is driving Casey to go public about his situation and his fellow GPs. We travel down a small road which is more pothole than surface and arrive at a small cottage near the sea. It’s a beautiful but isolated spot.

“When you visit a patient at home, you learn so much more about their situation – their diet, their comfort, their social interaction. And these are the very ill or infirm patients. I could mitigate the cuts by not doing home visits, but I can’t do that to my patients who need me.”

Analysis by the founder of Limerick University, Dr Ed Walsh, shows that Ireland has roughly 50% of the GPs of the average OECD country and about 40% of the hospital consultants. Yet, we are losing GPs every day and it is estimated that over 1,000 have emigrated in the last few years.

“We lost a doctor here. She was an excellent GP and also a psychologist, so we had started an adolescent mental health service here as well. She eventually left – thankfully we didn’t have to make her redundant, as that might have sunk us, and she went to Canada where she now makes $450,000 a year.”

Doctors like that are an invaluable resource that is being squandered. And, as usual, the cause is the inflexibility, lack of planning and thought in cutting back on resources. What will happen to Dr Casey if he is forced to close his practice?

“I could work out of a garage as a single GP, I suppose treating private patients. Or I could go to London where I’d make £1,000 a day as a locum. But I want to work here for as long as I can. I’ve been here 40 years and I want to work on until I can’t anymore.”

But mainly Dr Casey’s desire to continue on is a commitment to his patients. “General Practice deals with 95% of the patient interaction with the health service on 2% of the overall health budget. In the UK that figure is 8%. If we weren’t here and providing a stopgap for the hospital service, they would be overrun, patients would have to travel long distances and the whole thing would cost way, way more. Yet, the one part of the health service that people say is working – general practice – is being shredded and cut at a much greater level than any other area. It’s a recipe for disaster.”

“We had an autoclave machine here for sterilising equipment. If someone came in with a laceration, we could stitch it up. But now we can’t be confident of not infecting them, so they have to be sent to Galway. We have other machines that monitor blood pressure and other ailments and we have prevented many people from becoming very ill. But now we don’t have the money to replace these machines which cost several thousand euro. It means people will get sicker or will have to travel. It’s all avoidable”

Dr Casey’s situation is replicated right across the country. He says of the new contract that he would love to treat under 6’s and many more people for free, but he simply hasn’t the resources, and the extra workload would disproportionately hit his sicker patients.

“I had a man in here with terminal cancer. He has a wife and two children. His medical card was cut off. I will write the letters and spend a good deal of time trying to get it back for him, but you have to understand, in the west of Ireland when people get a brown letter with a box in the front, they often ignore it. They can’t necessarily deal with the bureaucracy themselves. To take a card from someone like that is just wrong, just because they can’t fill in complicated forms and provide every bit of documentation.”

What can be done to reverse this trend?

“We need to properly resource general practice. It’s not just one doctor. Here we provide eight jobs in a community where there is no industry. I can just about pay my staff, but I can’t pay myself. And all my staff have taken cuts to their pay and their hours. If they were deliberately trying to destroy general practice, they couldn’t do it any better.”

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