The National Association of General Practitioners says that the primary care system is close to collapse.
Terence Cosgrave talks to three doctors about the choices and challenges they face and why one doesn’t regret his decision to emigrate.
CUTBACKS in general practice have reached a breaking point, with many GPs operating at a loss or breaking even. It means that many will have to reduce their service to the public or even leave Ireland to earn a reasonable income. The result could be a devastating blow to general practice in Ireland – a service that is universally acknowledged by the public as the one area of the health service that works.
Dr David Janes, for example, is a GP in rural Waterford near the town of Clonmel. He says that last month he worked for nothing, as by the time he had paid for all his overheads, there was no money left to pay himself a salary. With a wife and three children, that position is untenable.
Dr Janes trained in Britain and has experience in emergency medicine as well as his GP training. For that reason, he already does emergency medicine work here and is called to the scene of accidents at a rate of about one a day. He does this work for free up to a 50-mile radius – despite the time it takes – and he says he has no objection to providing services for free, if he can make a living at the same time. The problem, he says, is that cuts to general practice under the FEMPI legislation have made it impossible for him to make any income at all.
“The cuts to general practice have affected rural practices even more than urban ones,” he says. “Before, if I visited a patient who lived far away out-of-hours, it was based on how far away they lived. Now, I get the same if the patient lives beside me or miles away, and if I have to travel a half-hour there and back and spend another half-hour with the patient, then I can’t be spending that time with someone else.”
He says the workload is getting tougher and higher in his practice. His patient split is about 50:50 between private and GMS patients, but he says in the last four years the private aspect has disappeared and now only one in five patients visiting his surgery is private.
Because the money paid by the HSE for public patients has shrunk so much, he says, he has no choice but to reduce the service he gives and eliminate free services in order to make some income. This is an option he wants to avoid at all costs, but he feels he has no choice.
Another GP in Cork is in the same boat. Dr Donal Punch trained as a GP in Leeds and returned to Ireland to set up a family practice in north Cork. He makes the point that GPs are responsible for 92 per cent of patient consultations, but receive only 3 per cent of the health budget.
He says that there is a huge list of overheads for which he is responsible, and that since his practice is almost totally made up of medical card patients, he is dependent on the income he receives from the HSE to get by. He built a purpose-built clinic for his patients several years ago to provide a better service and has an ongoing debt to service that new building.
He says that his business is a “thriving, successful business” in terms of patient care, but that financially, he hasn’t been able to withstand the “swingeing” cuts imposed by the Department of Health. There is now a waiting time of a couple of days in his practice to see him. He says he has huge outgoings in terms of his mortgage, medical insurance, heat and light, computers and staff; and that things that he used to do for free (such as blood tests and dressings) he is now devolving back to the public health nurse and the outpatients department.
He says he is “finding it difficult to keep the door open”, and that last month, his practice ran at a loss. Payments for some overheads had to be postponed until the following month.
“I have to concentrate on getting revenue into the practice, which is something I didn’t do before. Who it’s affecting is the patients because they are having to pay for services they used to receive for free, or go to the outpatients department. They’re also having trouble getting to see me.”
Dr Punch says that while the workload has increased, his compensation from the HSE has been cut by a third. He says this has made it more challenging for him to treat patients in an effective manner. He and his wife and children took their first holiday in five years this year to Lanzarote and when they returned, they found the cost of replacing him with a locum cost more than the holiday. The alternative is to let other doctors in the area pick up the slack, but that would mean an effective loss of service. In any case, it won’t matter as he doesn’t think his family can afford another holiday for a long time.
He says he has had to get personal loans from relatives to keep going. His overheads for a month are about €15,000 (including the cost of a second mortgage to buy into the practice) and before the last FEMPI cut he was just about making that. Now he is operating at a loss. Despite the fact that he is very attached to Ireland and to working in Ireland, he and his wife Una (who is also a part-time doctor in the practice) have begun to look at the prospect of moving abroad.
“She is a real home bird, but lately she’s been looking at options abroad in Canada. I was always willing to travel anywhere, but she wanted to be here. But now we don’t see any option. We have no negotiating power. We’re being actively ignored by the powers that be and we’re being railroaded into the service being cut to shreds. The minister isn’t listening to general practitioners.”
Canada is just one of the destinations for Irish GPs, and the difference in working conditions and pay is enormous. Dr Sunny Chan grew up in Belfast, where his father worked as a waiter in a Chinese restaurant for 30 years to put him through medical school in Queens University. After a period teaching at the Royal College of Surgeons and working part-time as a GP, he applied for a GMS list and got it in Ballymun – a big list with 1,950 patients.
He says the HSE was unable to help him find a suitable premises, and that thankfully he didn’t buy into the new primary care building in Ballymun – at Celtic Tiger prices– which would have trapped him here. Instead he opened his practice in a shopping centre, but after a few months he realised he was not making enough to pay himself a salary – let alone staff – so he moved to Ottawa, Canada.
He had been offered jobs in New Zealand, Australia and Canada. In Canada alone, when he visited for a week, he was offered a job by 12 different practices. And he says that the difference between there and here is huge in terms of work-life balance, stress and financial support.
Doctors in Ottawa work as private contractors to the Ontario Health Insurance Plan (OHIP), and doctors then bill OHIP for the patients they see. Therefore, the more work they do, the more they get paid. As doctors are self-employed, they work whatever days or weeks they choose.
He is “very happy” with his decision to move abroad and he may be the vanguard of a much larger movement of Irish GPs deciding to emigrate. He says he has “no regrets” and that the quality of his life and his family’s lives are “incomparable” with the situation he was in when he was in Ireland.
For many other Irish GPs, Dr Chan’s solution may provide the only option for making a decent living in the near future, unless there is a change in health policy with regard to primary care.
But the destruction of primary care as one of the most effective areas of the health service would be a disaster which would take years to reverse if it happened. Unfortunately, given the financial constraints on the health service and the lack of appreciation of the role of primary care, it looks like many more GPs will either have to cut back on services severely, or take the emigration route.
-This article originally appeared in The Sunday Independent here: http://www.independent.ie/opinion/analysis/terence-cosgrave-why-its-crucial-the-state-heeds-warnings-of-gps-29779451.html#sthash.0dQt0lEC.dpuf