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Doctors ‘under attack’, says new IMO President

Dr Gilligan, a Consultant in Emergency Medicine at Beaumont Hospital, Dublin, delivered his inaugural address at the Organisation’s AGM in Killarney following Minister for Health Simon Harris’s speech.

The IMO President said Irish society had very significant expectations of those who wished to become doctors. However, he said doctors were being routinely dishonoured by having contracts ignored, having to tolerate different pay rates for similarly-qualified doctors doing the same job, and unreasonable delays in restoring cuts imposed during the crisis compared to other groups.

The consequences included 400 consultant posts unfilled nationally, GMS lists without a GP and “more resignations from the public hospital system than ever before in the history of the State”, he said.

“The fact that new contracts need to be negotiated for GPs, NCHDs, consultants and public health specialists is indicative of the fact that doctors in Ireland currently do not feel valued,” Dr Gilligan commented.

This issue fed directly into the unprecedented shortage of doctors in key posts across the country. Dr Gilligan recounted a personal experience of a colleague who resigned his post recently, saying that he could no longer work in a country where he was embarrassed to tell people he was a consultant. 

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Dr Peadar Gilligan, IMO President

He also described the need to board admitted patients on trolleys and chairs in emergency departments (EDs) as “an absolute outrage”.

The IMO President maintained that Ireland is an outlier in terms of ED overcrowding internationally and called for the introduction of a six-hour standard between the time a patient arrives in an ED and the time they are admitted or discharged. The current average waiting time in EDs in Dublin is 14 hours.

On proposals to increase the number of beds available in the system by just over 2,500, Dr Gilligan said the country needs over 7,000 new beds to deal adequately with an increasing and ageing population.

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Reform of consultant appointment process will be ‘high priority’

Speaking at a seminar for NCHDs at the IMO AGM in Killarney, Prof Murray said the decrease in the number of approved consultant posts in the last two years was “disappointing”. According to information presented by Prof Murray, there were 174 consultant posts approved in 2017, compared to 195 in 2016 and 288 in 2015.

“That is disappointing to me; that is something I am going to make a very high priority, to see what we can do to facilitate the appointment of consultants in a more easily-negotiated way.”

He outlined that Ireland required “far more consultants and general practitioners” and that “we need to look carefully at the ratio of NCHDs to others within the health service”.

Figures presented by Prof Murray showed that Ireland has 77 consultants per 100,000 population, compared with 106 in the UK. He said the number of non-training NCHDs had increased by 50 per cent in the last four-to-five years, but specialists and trainees should instead be the focus of substantial increases.

He said the “big drive” in relation to non-training NCHDs was a reflection of European Working Time Directive (EWTD) implementation and there had been a “failure to plan adequately in relation to that”.

Prof Murray said a working group would be established on the issue of non-training NCHDs. He reiterated his support for an amendment to legislation that would allow non-EU NCHDs to access the trainee division of the medical register where their internship was not deemed equivalent.

His focus would also be on progressing outstanding issues affecting trainees, including protected training time, allocation of non-core tasks, educational refunds and non-payment of overtime.

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Harris promises ‘real progress’ on GP contract as frustration mounts

However, GPs at the meeting expressed major frustration at the delays on a new contract and FEMPI reversal, with no confirmation that restoration of fees would be unconditional.

Minister Harris acknowledged that “GPs suffered a lot during the recession”.

Speaking to journalists, he said “many cuts” were made to general practice funding by successive governments “during the financial emergency”. He said “now, as we move as a country to a better economic climate, it is important to try to help general practice”.

Minister Harris said talks would commence within a month and he wanted to “move to a post-FEMPI era”.

“I want to engage with GPs. I want new services they can also provide within the community to help reform our health services, and yes, there will be significant resources available and my message to general practice tonight is, this is the moment you have been waiting for.”

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Simon Harris, Minister for Health

This would be subject to reaching an agreement on a new contract through “intensive” talks with the IMO and other stakeholders, the Minister added.

There was also anger among GPs at claims in a Department of Health briefing document that FEMPI cuts to general practice amounted to 24 per cent, compared to the 38 per cent figure quoted widely by GP representative bodies.

Minister Harris said he was “not here to get into a row over the IMO figures and percentages”. He said it was “not under dispute” that general practice had “suffered over the years of recession”.

“We now as a Government have significant extra millions of euro that we want to spend in general practice and I want to engage with GPs on how to make this a reality, and that will happen within a month.”

The Minister would not clarify whether the unwinding of FEMPI would be conditional on “service improvement”, as suggested by Minister of State at the Department of Health Jim Daly at the NAGP AGM last month. Minister Harris told journalists he wanted “holistic” talks and stressed that new services would be resourced.

Minister Harris also insisted to the Medical Independent (MI) that the forthcoming talks would result in real progress on a new contract “within months”. He had briefed Government in late March and now had legislative powers to set fees.

“What is different now is that these are talks that are mandated by the Government, these are talks that I have been liaising very closely with the Department of [Public] Expenditure and Reform on, and they are talks backed-up by resources. Obviously, I am not going to put the figure in the public domain because that is the purpose of negotiation, but what I can say is, we are talking about wanting to spend many, many millions more in general practice over the coming years.”

Responding to questions from MI about the further expansion of free care to under-12s, as contained in the Programme for Partnership Government, Minister Harris said he would “like to see the extension of access to GP care provided”.

However, he was “also conscious that I have both the Programme for Government commitments and the Sláintecare programme as well, which talks about expanding access, and I’d like to talk in the negotiation structure about how best that can happen”.

According to Minister Harris, he had said “many times” that “the cost of going to the doctor is a factor that many parents reflect on heavily when they have a sick child”.

However, he said he wanted to make progress in a “sustainable manner”.

“Ministers for Health in the past have just wanted to talk to GPs about one issue… I want to talk about a range of issues. I want to talk about the current level of fees. I want to talk about future services. I want to talk about how we make Sláintecare reform a reality. I want to take a multi-annual approach to this. I suppose I am in a position that many of my predecessors weren’t — that we do now have resources to make this possible if we have willing partners, and I believe we do.”

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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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