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.Read More
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.Read More
According to Donegal Coroner Dr Denis McCauley, there is a lot of confusion in relation to the finding of medical misadventure.
“Essentially, it means death while under medical care and it does not imply any fault by any parties. Unfortunately, in tort law, medical misadventure is primarily viewed as it was the ‘doctor what done it’. It is the perception of medical misadventure that I feel is [not accurate]. I would rather just use the term ‘death while under medical care’,” he told the Medical Independent (MI).
Dr McCauley gave the example of babies dying during high-risk operations, saying that the risks would have been explained beforehand, the child was also likely to die without the procedure and the medical team did their best, but that death could be recorded as death by medical misadventure.
“An inquest cannot lay blame. You can only look at facts, so I think medical misadventure is being used [unfairly]… It is just the perception of it and I think if we just had a more benign finding, there would be less contentious inquests.”
During his talk on the role of coroners, Dr McCauley said that when patients die in nursing homes during the night, in cases where death is not unexpected, it is okay to wait until morning to have the GP attend and sign a death certificate.
He also told MI that a plan to have senior nurses in nursing homes pronounce death under prescribed circumstances is to go ahead “in the near future”.
The National Policy for Pronouncement of Expected Death by Registered Nurses (for use in HSE residential, long-stay and specialist palliative care services only) was approved by the HSE Clinical Strategy and Programmes Division in July 2017.
Meanwhile, speaking from the floor during Dr McCauley’s talk, Dublin GP Dr Ray Walley highlighted the vital role of GPs in signing death certificates promptly, avoiding delays for grieving families. He warned that the GP manpower crisis could impact this service in the future and Ireland could then end up like England, where bodies are not buried for weeks.
During his talk, Dr McCauley also highlighted that recent difficulties with the continuation of the post-mortem service in Donegal, where approximately 150 post-mortems are performed annually, have now been resolved. “The presence of a post-mortem service is vital for the running of a coroner’s [work] and the service is Letterkenny [Hospital] has now been guaranteed by the HSE, and I really welcome that,” he told MI.Read More
Medical Director of the PHMP Dr Ide Delargy, who presented on the PHMP at the IMO AGM in Killarney, said the programme had noticed “a trend” in terms of presentations of doctors who qualified through GEM courses. However, doctors present from a range of backgrounds and the programme has not yet compiled data on GEM and direct-entry graduate presentations, she noted.
“What becomes evident is the additional stresses that they would have; they are later in their career anyway, de facto, so they are at a different stage in life; maybe they have a young family plus the financial burden of having gone back to take up a course in medicine,” Dr Delargy told the Medical Independent (MI).
She said a combination of factors brings people to a tipping point “and I think the graduate-entry people are, if you like, a little bit more susceptible because of the additional stress that they would be experiencing, so we have certainly picked up on that as a little bit of a trend. Obviously, not everyone who is attending is in that category but it is certainly something we are noticing.”
The PHMP was launched in September 2015 to provide support, advice, treatment and monitoring for mental health and substance misuse issues facing doctors, dentists and pharmacists. It is also open to medical students.
In her presentation, Dr Delargy emphasised that the service is free, independent and strictly confidential. The PHMP has a memorandum of understanding with the Medical Council and is not required to disclose information about a practitioner unless serious concerns arise in terms of their compliance with the programme or in relation to patient safety.
Doctors tend to be high academic achievers with strong perfectionist traits who work in highly-pressured environments, outlined Dr Delargy.
“I think it would be fair to say that most people who make it through medical school and get their qualification are pretty resilient — they’ve gotten over a lot of hurdles to get where they are,” said Dr Delargy.
“But all resilience has a limit and what we find is that the combination of factors is what often puts people over the edge — so, workplace issues, conflict, bullying, the increased patient demands, the management demands, the time pressure, the emotional demands, and moving jobs, that is another key time when people can often become disconnected, they become disconnected sometimes with their friends, family and even their primary carer, if they do have a GP… ”
There are also personal matters associated with health, relationships, family matters, finances, bereavement and unresolved grief.
A key issue is doctors’ access to pharmaceuticals as they seek to manage their own health.
The majority of presentations to the PHMP involve doctors and most self-refer. Mental health issues predominate, followed by substance misuse and a combination of both. Dr Delargy said the barriers to presenting to health services include stigma, fear for reputation and confidentiality concerns.
Doctors often try to self-manage mental health and/or substance misuse problems, which compounds matters further, she explained.
“What we would be saying is that small and persistent changes in behaviour and performance need to be taken seriously — so, the persistent changes that are lingering. Usually, the workplace is the last place where signs of impairment will appear; they will keep a huge degree of functionality with their work but behind the scenes, it can often be chaos, and I mean real chaos… by the time somebody appears dysfunctional or impaired in the workplace, things are very far gone.”
Changes in appearance, increasing irritability, being uncontactable, isolation and hyper-vigilance are some of the signs to be aware of.
Colleagues often miss — or choose to miss — signs that someone is experiencing these types of difficulties, yet pointing them in the direction of help could be life-saving as well as career-saving.
The PHMP is aware that it must tread a delicate line in balancing physician wellbeing and patient safety, noted Dr Delargy.
“Our reputation is destroyed if we are allowing a practitioner to work in a particular way that puts patients at risk. But obviously, we’d try and keep an eye on physician wellbeing as well. If the focus is entirely on patient safety, we miss opportunities in terms of physician wellbeing — we know the consequences in terms of a doctor being unwell [without support] looking after patients, we know it increases medical error, prescription errors, more likely to have adverse events, more likely to have complaints. So it is important that we keep that balance and focus on both sides of that tightrope.”
Over 80 per cent of practitioner patents get back working safely and well, Dr Delargy underlined.
Some 36 doctors presented to the PHMP in 2017, with 21 being NCHDs.
For more information, visit www.practitionerhealth.ie.Read More
In his talk on the economics of providing new treatments and medicines, Prof Barry argued for the mandatory collection of health outcome data following reimbursement of high-cost drugs.
He said State deals with pharma should involve ongoing provision of data on the impact of high-cost medicines and the State should get its money back if the drug is “not working”.
Much greater use of biosimilars, a prescribing incentive scheme for general practice and review of the long-term illness (LTI) scheme are also required, with Prof Barry being of the view that the latter scheme should be scrapped in its current form.
He said the LTI scheme was “inequitable” in terms of the medical conditions included and excluded, and noted as an example that “you could be the wealthiest diabetic in the country and you get your diabetic medicines free… ”
Prof Barry’s presentation outlined that the State was reimbursing numerous drugs far in excess of the cost-effectiveness threshold utilised by the NCPE and yet this should only happen in exceptional circumstances.
In 2016, total drugs spend was over €2 billon, increasing by 4.6 per cent on 2015.
Prof Barry said the high-tech drug scheme accounted for less than 1 per cent of items dispensed but outlay in 2016 was around one-third of the total drugs expenditure.
He said it was “right and proper” to talk about medicines and money because of the ‘opportunity cost’.
“If we spend money on medicines — millions and millions on medicines — it may not be available for our cath lab in Waterford, for correcting scoliosis in our children, looking after our elderly people at home. We’d be far better off investing some of the millions of euros we put into drugs to looking after our elderly patients — your relatives and our elderly patients — I feel strongly about that. Disabilities and mental health — yes, that is where we need to put our money, not into drugs or all drugs.”
Prof Michael Barry, NCPE
The NCPE, which conducts the health technology assessments (HTAs) of pharmaceutical products for the HSE, is seeing more and more high-cost medicines. The highest-cost medicine in the country is Soliris, made by Alexion. It is indicated for paroxysmal nocturnal haemoglobinuria and atypical haemolytic uremic syndrome (aHUS) and costs €582,000 per patient per year for aHUS.
“That is what we are dealing with on a regular basis now. We are now in the middle of assessment for a drug that will cost about €1 million per patient per year… ”
When the NCPE conducts HTAs, the onus is on the industry to make their case, said Prof Barry.
“It is up to the industry to prove that its product is value for money and that we should be using taxpayers’ money to pay for it… it is their challenge.”
The Centre examines the added value for the increased cost as compared to the standard of care. The quality-adjusted life year (QALY) threshold used in the HTA process is €45,000
“So if you are below that, in other words, if you are getting good value for money, we will be saying yes, we will be recommending it… Essentially, what we know now is that if it’s above €45,000 per QALY, when we spend on that drug, someone is going to lose out.”
Prof Barry discussed the impact of media reporting and political pressure surrounding recommendations on drug reimbursements.
Among the drugs discussed by Prof Barry was Kalydeco (ivacaftor) and Orkambi (lumacaftor — ivacaftor). He noted that “we await” peer-reviewed scientific data to demonstrate the impact of these drugs on CF morbidity and mortality.
On Orkambi, at the time of assessment it was €159,050 per patient and the budget impact was €391 million over five years. It was €369,141 per QALY. “… This is why we should do cost-effectiveness analyses on drugs for rare diseases, because it shows us what price we should be getting, and in fairness to the HSE, for a lot of other drugs they use this information to ‘hard bargain’ with the company in relation to drugs, and that’s what they did on Orkambi. They didn’t get it to where we wanted, but they reduced it by about half… ”
Prof Barry referred to a “very interesting clause” in the IPHA agreement, stating that where the HSE cannot fund a drug from within existing resources, it may inform the Department of Health, which may bring a memorandum to Government in relation to the funding implications.
He expressed concern at a proposed amendment to legislation that assessment for value for money for very high-cost drugs for rare diseases (orphan medicines) was “not relevant”.
“Why were we able to reduce the price of Orkambi by nearly 50 per cent — that is in the media… the reason we were was because we were doing economic evaluation, because we were able to front-up to them.”
Prof Barry said he was “reliably informed” that the pharmaceutical industry was in Dáil Éireann “every single day”.Read More
Consultant members passed a motion condemning the Government and the HSE “for effectively forcing individual consultants to resort to legal action in the High Court in order to have their contractual rights” upheld under the 2008 Consultant Contract.
Speaking at the Organisation’s National Consultant Meeting, Consultant Rheumatologist in Connolly Hospital, Blanchardstown, Prof Trevor Duffy reflected on his own experiences during the negotiations for the 2008 contract.
“This stands for so much more that the simple fact of money. It just displays intent, approach and belief on behalf of the Department of Health and Government,” said Prof Duffy.
“The Government’s case on this issue is untenable… yet they are still insisting on dragging it through the High Court.
“I think the display of what that says in action is far more important than the money itself. It displays a complete contempt for consultants and for the medical profession. It is really hard to see how you can enter into good faith negotiations while this kind of thing is carried on in the background.”
Consultant in Emergency Medicine Dr Mick Molloy described the current situation as “frustrating”.
“Talks stall for various reasons, I understand that,” said Dr Molloy.
“But when you walk out of a room with what we thought was an agreement only to find out a year later, we are told ‘well, actually, the salary wasn’t agreed’…and that they were no longer going to honour the deal a year after the fact.
“It makes you wonder can you actually negotiate with this group at all in the future without having cast-iron guarantees in advance that a particular contract will be honoured in the future.”
Dr Molloy told the meeting that his understanding was the Government and HSE would appeal if the legal cases go against them.
“So that would be a very lengthy process, very expensive process, very unnecessary process,” he added.Read More
At the National Consultant Meeting, members discussed the recommendation in the Sláintecare Report to separate private practice from public hospitals. The Government is currently undertaking a review on the implications of this recommendation.
“I know what the value to our small hospitals is, from the income source from the [private] patients,” said Dr Mick Molloy, Consultant in Emergency Medicine.
“If that was taken away, I’m very concerned about how it would be replaced, and there isn’t a mechanism in place to actually cope with that lost revenue.
“And I would fear that the knock-on effect would be more patients seeing they can’t get access to public hospitals will [then] ditch private insurance and [then] there will be a greater volume of people coming into the public hospitals, with a lesser amount of money to deal with it. That is the situation that would be the worst of all scenarios.”
However, Consultant Psychiatrist Dr Matthew Sadlier questioned the very basis of the debate regarding public and private patients. He told the meeting that all reports and plans, including Sláintecare, do not take into account the complexity involved and are thus flawed.
“I’ve said this for 10 years and nobody ever listens or reports it,” said Dr Sadlier.
“We do not have a two-tier health service. I just wish people would say this: We have a three- or four-tier service. We do not have one set of private insured patients and then those with no insurance. We have a range of insurance options that gives you a range of access to private care.
“There isn’t really a private patient and a public patient; there are many shades of private patients. Most people who take out private insurance do not take out insurance to the level that allows them access to standalone private hospitals. So this concept of 47 per cent of the population having private insurance; they don’t really, they have semi-insurance.”
Dr Sadlier told his fellow consultants that this flaw in analysis has impacted political policy towards health.Read More
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.
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.Read More
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.Read More
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.”
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.”