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Call for improved NCHD rota system and contract review at national meeting

The meeting passed a motion calling on the HSE to provide NCHDs with four weeks’ notice of their initial roster.

The HSE is contractually required to provide two weeks’ notice of the first NCHD roster of their rotation, but IMO members said this is not always happening.

“I have been a doctor for nine months now and have never had a rota with two weeks’ notice,” said Dr Neasa Conneally, “so four weeks would be great.”

NCHD Committee Chairperson Dr Paddy Hillery told the meeting that NCHDs were not working normal nine-to-five, Monday-to-Friday jobs.

“It is important that you are given proper notice, that they [HSE] take your life into account,” he said.

Also at the National NCHD Meeting, former IMO President Dr John Duddy said it was time for a review of the NCHD contract.

He recalled how the previous contract emerged eight years ago after long meetings and threats of industrial action.

“That is not the way we want to negotiate a new contract,” said Dr Duddy.

“Nobody here wants to go through that again with a year-long process; that was extremely stressful for everyone involved. A more constructive way of doing it would be to institute a more formal review with our employer.”

The meeting passed a motion calling for a contract review.

“This is what we want to be engaging on, what we want to be doing,” said Dr Hillery.

“As a union, we do not want to be dragging people out on the streets to get the basic improvements that we all agree are necessary. We want to engage proactively with our employers and work for the betterment of our patients and our practice.”

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General practice ‘will go over the cliff’

Discussing a motion that called on the Minister for Health and the HSE to acknowledge the current workforce crisis in general practice, whereby 700 GPs are due to retire in the next five-to-seven years “with no prospect of new GPs taking over practices”, Kilkenny GP Dr Tadhg Crowley said it was not only a problem of retirement and recruitment.

He said that once one doctor goes, more will follow, as the workload will be unsustainable.

“I think it will be an explosion when it happens; we will go over the cliff like we have never seen before in the country.”

Dr Michael Kelleher, GP in Lahinch, Co Clare, said “we urgently need to address capacity issues, we urgently need to restore FEMPI to repair our existing service”.

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General practice not in ‘good place’ — HSE DG

Mr O’Brien was speaking to MI following a debate on the Sláintecare Report at the IMO AGM in Killarney.

The debate heard from a number of IMO GP members, who described what they believed to be the current crisis in general practice. A number of speakers also questioned whether the intention of the Sláintecare Report to establish a primary care-focused health service was possible, considering the current state of general practice.

“General practice is vital to the future of the health system,” Mr O’Brien told MI.

“Clearly, we are not on the right track in terms of sustaining the type of general practice service that we need. So one of the things clearly articulated in Sláintecare must now be translated — that is for a vision for the future of general practice that will bring confidence to doctors.”

Mr O’Brien said doctors who are in training must be encouraged to enter into general practice and know it “has a sustainable future, appropriately funded, appropriately resourced”.

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Sláintecare statistics called into question

Chairperson of the union’s GP Committee Dr Padraig McGarry raised the issue with GP Dr Michael Harty TD, one of the authors of the Sláintecare Report.

“Some questions have been asked in relation to the gathering of statistics,” said Dr McGarry during a well-attended debate on the Sláintecare Report on the Thursday evening of the AGM.

“We know the accuracy of statistics for the production of this report is absolutely essential.”

In his response, Dr Harty admitted that there may be some problems with the statistics used regarding GP visitations.

“There is a controversy over the visitation rates in relation to general practice,” said Dr Harty.

“I have spoken to the Trinity [College] group [who worked on the report] who are willing to look at those figures. I know [Dr] William Behan has very strong views on visitation rates [figures]. I would think his figures are more accurate than those used in the [Sláintecare] Report. But those were the figures that we took from the Trinity group.”

Dr William Behan is a GP who has queried the Sláintecare Report statistics regarding general practice on his Twitter account (@DrWilliamBehan) and elsewhere.

“I think if Sláintecare is to be introduced, if there is to be an expansion of primary care, if there is to be an expansion of entitlements, those figures will have to be looked at closely,” added Dr Harty.

“I think it is in that context that they can be negotiated and reviewed.”

In response, Dr McGarry said there was “a slight urgency here” because negotiations over a new GP contract are taking place.

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Expert group should examine potential of decriminalisation

The proposer of the motion, Dublin GP Dr Cathal O’Sullivan, told the Medical Independent (MI) that he believed the motion was important in getting the issue discussed publicly.

“The issue has been exposed and talked about. That is sort of the purpose of this motion; it is to get more discussion going,” Dr O’Sullivan told MI.

“People need to sit down and look at the facts and look at what is happening in the US, in Portugal, in Canada, places where a more rational and evidence-based approach to treatment is happening.

“Look at what is happening there and examine it and see and talk about it. Drug treatment is a very emotive issue; people don’t always look at the evidence. People have these ideas in their head — they are against it or they are for it.

“People need to sit down and look at the facts and examine what is happening in the country, what the outcome of these things are. Then make decisions. It will take time — we are quite slow in advancing. That is not necessarily a bad thing, to be cautious and to look and see what is happening.”

Dr O’Sullivan added that he believed the medical profession and the IMO “definitely” have an important role to play on this issue.

The AGM also passed a motion calling on the HSE to urgently discuss with the union the best way to deliver general medicine and drug treatment services to the homeless.

“I think the way to deal with this problem is to empower and resource GPs who are willing to deal with the problem,” Dr O’Sullivan told MI.

“Because the best place to treat homeless people is in general practice if it’s at all possible. Big clinics, especially big clinics full of homeless people, would not be good places to treat people… We need to give people holistic care; they need medical cards, etc.”

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Sláintecare comes under fierce criticism from IMO delegates

New IMO President Dr Peadar Gilligan was scathing about what he regarded as the lack of engagement with the medical profession and also the lack of detail in the report.

“I would expect that there [would] be a terrific evidence-base. I would expect that the implications have been considered… in great detail. I just didn’t get the impression, and I still don’t have the impression, that has been the case with Sláintecare.”

Dr Gilligan, a Consultant in Emergency Medicine, said he thought there was “an attempt in Sláintecare to pit general practice against hospital medicine”. He queried the basis of moving the focus of the health system to primary care.

“How are we going to address the tens of thousands of people on waiting lists, waiting to see specialists, and the waiting times we have in emergency departments around the country?”

“I have heard the expression that this is ‘the only show in town’ quite a few times, but some of us have been around long enough to have seen lots of shows in town come and go.”

Dr Gilligan’s concerns were echoed by a number of GP members of the IMO.

“I read the report from cover-to-cover,” said Co Waterford GP Dr Austin Byrne.

“While I found the report very admirable in terms of its content and aspiration, I felt that the technical side of the report was really quite lacking in terms of detail about manpower.”

Monaghan GP Dr Illona Duffy said she thought the report was “unfortunately light on how it’s going to happen”.

“When we can see that people [presently] cannot even sign on to the [local] GP when they move to a new area, when we find that we can no longer offer that same-day service that we did, we are morphing into the NHS GP system.”

Dublin GP Dr Ray Walley said he had significant concerns with the report, saying the focus should be on improving GP services now.

GP Dr Michael Harty TD, who was one of the report’s authors, said it acknowledged that entitlements could not be expanded without appropriate capacity in general practice and hospital care.

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IMO urges improvement in emergency planning

Union members passed a motion calling on the Executive and “regional emergency management offices to engage with all emergency departments when exercises are being planned in the community so as to ensure opportunities for shared learning are maximised”.

“There are a lot of planning exercises that take place in the public health arena, in the pre-hospital emergency care arena, in the fire service arena, in the Garda arena. They don’t all interact,” said Consultant in Emergency Medicine Dr Mick Molloy.

“Or if they do, they don’t certainly interact with our local receiving emergency departments. So we get kind of left out. The practice exercises happen, all those relationships get built, but when the true emergency and disaster happens, they come to the local hospital and go ‘why does it not work?’ Because we haven’t been engaged in the exercise.

“So this [motion] is trying to get everyone playing on the same field, to advance our own systems and network to respond to these situations.”

IMO NCHD Committee Chair and trainee in emergency medicine Dr Paddy Hillery said he supported the motion, “having taken part in one of these events — from the hospital side, it was a great learning experience”.

He added that practice and interaction between the different services was vital preparation for any serious emergency event.

Separately, the AGM passed a motion calling on the Department and HSE to “fulfil their national and international obligations to develop and implement strategy to respond to chemical, biological, radiological or nuclear incidents, whether unintended or due to terrorist activity, and which may result in mass casualties, including the provision of adequate resources.”

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Inappropriate NCHD pay deductions ‘unacceptable’, admits HSE HR chief

Dr Charles Goh of the NCHD Committee said there was “a degree of non-transparency with regards to payroll”. He said “inappropriate” pay deductions was a recurrent theme at Committee meetings. Dr Goh was speaking on behalf of members at a seminar titled ‘Where Now for HSE HR Values for NCHDs?’

In response, Ms Mannion advised that the National Integrated Staff Records and Payroll Programme will align HR and finance data, but it is not expected to be completed for another 24 months. She said in the interim “we need to put in some mechanisms, certainly around transparency”.

“We unfortunately have limitations in terms of our business systems and our IT systems due to a lack of investment over a period of at least 10 years, in that we do need to align HR and finance. At the moment, in many of the hospitals, the HR system and the finance system do not talk to each other,” she outlined.

Speaking specifically on the issue of non-payment of overtime, former IMO President and NCHD Committee member Dr John Duddy informed Ms Mannion “we have seen earlier this year at certain specific sites where NCHDs are not being paid properly, and that has been a running sore since I have been an NCHD for nearly 10 years now. While the HSE Values programme is fantastic, the work you guys are doing at a national level is fantastic, how do you propose to make that filter-down to clinical sites on the ground so that HR managers and medical workforce managers actually implement policy and how are you going to hold people accountable for that?”

Ms Mannion said “it comes back to accountability” and it is “something we need to do better on, in terms of the whole leadership and culture across the health sector”.

She said that when a policy is signed-off at national level and is not implemented at a particular location, “we are all undermined by that”.

Asked by the Medical Independent (MI) what measures would assist national HSE managers in clamping-down on non-payment of unrostered overtime, Ms Mannion said national pay agreements must be implemented.

“From our point of view, it is through constructive engagement and dialogue with each of the Hospital Groups and the Chief Officers that we make sure that national policies are implemented; alternatively, we are going to have industrial unrest,” she told MI.

Asked if there were extra powers that the HSE Leadership Team would like to have to ensure implementation at local level, Ms Mannion said most sites implement payment of NCHD overtime and a “punitive” approach would not work in respect of non-implementation.

“Our focus has to be on bringing everyone with us and working constructively,” she said.

Initiatives such as the Leadership Academy would assist in developing the right culture and leadership in the health service, she told MI.

Prof Frank Murray, newly-appointed Director of the HSE National Doctors Training and Planning (NDTP), also spoke at the seminar and underlined his commitment to helping resolve a range of issues affecting NCHDs.

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Recommendations awaited from public health doctor staffing report

The Crowe Horwath report was commissioned following a recommendation in the 2014 MacCraith medical training and staffing report, which highlighted the low levels of doctors in the specialty (60 in February 2017) and significant recruitment and retention problems. The new review, which was due to be finalised last June, examines the attractiveness of public health medicine and the curriculum and content of the specialist training scheme.

Outgoing IMO President and member of the IMO Public Health and Community Health Doctors Committee Dr Ann Hogan told the Medical Independent (MI) that the report’s recommendations have yet to be shared.

A motion at the Committee’s national meeting at the IMO AGM calling on the Department and HSE to publish the report and to engage with stakeholders on its implementation without delay was carried unanimously, as was a motion calling for all specialists in public health medicine to be granted consultant status.

Dr Hogan pointed out that training for public health doctors is extensive, the role of public health medicine is increasing, and they are now providing an out-of-hours on-call service, yet “they are still not on anything like a consultant’s contract”.

In relation to community health doctors, Dr Hogan said there had been some recent progress in Munster regarding a number of area medical officers (AMOs), who have been upgraded to senior medical officer (SMO) level or put on a pathway to achieve this. However, some AMOs are still waiting for this to happen, despite years of promises and growing demands on community vaccination services.

 “If we have posts left vacant for months on end, the services are going to suffer… at the moment, we have an outbreak of measles in Limerick. The role of the community health department involves giving the MMR vaccine in primary schools and if we don’t achieve the uptake we need, we are going to have more and more outbreaks like that.”

Dr Hogan also spoke at the AGM on the role of vaccination, highlighting the challenges posed by the Internet in facilitating the spread of anti-vaccine propaganda and ‘fake news’, and the increasing phenomenon of anti-expert bias.

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Pressure on sick doctors to organise their own cover

In a Q&A session following a seminar on doctors’ health, speaker Dr Blánaid Hayes, Dean of the Faculty of Occupational Medicine, RCPI, noted that the booklet for NCHDs at Beaumont Hospital, Dublin, has a paragraph outlining that doctors are expected to find their own sick leave cover. She said this issue “has incensed me since I started working there”.

Dr Hayes said doctors were “unique” among employees of the health service in having to get their own cover when sick.

“It is absolutely ridiculous,” she said. “I remember we had one young man down one day [in the department], he was really miserable with norovirus, vomiting in the toilet, shouldn’t have come down to us of course, should have gone straight home, but his overriding concern was that he had been told he had to get cover for himself.”

Dr Hayes, who led national research on the wellbeing of hospital doctors in Ireland, which found one-in-three suffered burnout, commented: “These are the systems challenges that we have to challenge; to say it is not okay to get sick people to assume the responsibility of having to get cover. But the problem too is that there is no slack in the system, so that if one is down, the whole system creaks. It is already creaking anyway… I think we have to change some of those old habits. It has been like this forever and other employees wouldn’t dream of tolerating it.”

Dr Illona Duffy, a GP in Monaghan, said many doctors feel they cannot take sick leave due to the nature of their responsibilities and the pressure it will put on colleagues.

She said when doctors enter training, they must be assured that it is okay to be sick and be encouraged to have their own GP.

Dr Duffy also spoke about the impact on doctors of patient suicides and the lack of support for GPs following these tragic deaths.

She said while debriefing and counselling for healthcare professionals following patient suicides happens in other areas of healthcare, there is no such process for general practitioners.

In the last five years, there had been six suicides of patients in her practice, “all of whom I had personal dealings with and three of whom I went to pronounce as dead. No counselling was provided to me at any stage… and that is something that will always impact on you and you will always remember.”

Speaking to the Medical Independent (MI), Dr Duffy said: “Often, these are patients we have known for years and there is always a question; you always feel, did you miss something? You are dealing with the loss of the patient and what this meant to you… but also dealing with the after-effects on the family who are traumatised.” Pronouncing a patient dead in such circumstances can be very harrowing for GPs, she added.

While GPs can informally engage with colleagues to discuss their feelings, a formal support process, as occurs in hospitals,should be in place, said Dr Duffy.

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