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ICGP AGM, 25-26 May 2018

Transfer of training process suspended, ICGP meeting hears

The HSE has been informed by ICGP CEO Mr Fintan Foy that the process of transferring GP training delivery to the College has been suspended until industrial relations (IR) issues are resolved between the HSE and programme directors. The announcement was made on the second day of the College’s Annual Conference in Dublin on 25-26 May.

The issue of the transfer of training from the HSE to the ICGP was the subject of 10 motions submitted to the Board, the AGM heard. The Board presented a motion to the AGM incorporating members’ concerns. This was passed and negated the need to debate further motions.

As previously reported by the Medical Independent (MI), the ICGP agreed in 2016 to a funding reduction of over €3 million under the proposed transfer. It has been anticipated that the number of programme directors/assistant programme directors will reduce significantly and the roles will be reconfigured with reduced pay.

As MI reported on 28 May, an independent mediation process involving the IMO and HSE, which aimed to address the employment rights of programme directors and assistant programme directors, had failed.

Speaking prior to discussion on the Board’s motion, Mr Foy told delegates the transfer process was “one of the most difficult, challenging change projects that I have been involved in. That challenge has not been getting any less; if anything, the challenge has been increasing… Before we can move forward, we need to stabilise the current situation and I think that is where we are at.”

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Mr Fintan Foy

Mr Foy said he wanted to acknowledge publicly the work of the programme-directing staff over the past 30 years.

“And undoubtedly, their engagement in this process and at an earlier stage would have helped the current impasse that we are in at the moment. So communication from the College over the last period of time hasn’t been great and I think we will make a commitment to improve that, but communication is a two-way thing as well. So as we do what we need to do, we hope that everybody else who is involved in the delivery of training will work with the College. I think, collectively, we are strong and individually, we are weak. And individually, we will be taken apart so I think it is very important that as we move forward in what is one of the most critical projects that this College has ever undertaken in the last 30 years, that we are unified… ”

The motion from the Board stated that “in the context of the transfer process of the responsibility for GP training from the HSE to the ICGP, the Board of the College will guarantee that the quality of existing GP training will be preserved, maintained and enhanced through comprehensive, effective engagement and consultation with all key stakeholders”. The motion added that when the “transfer change management project has been completed”, it will be formally approved at an EGM convened by the Board (under Article 6.4 of the Articles of Association).

There was a broad welcome to the Board’s motion. Programme Director of the Cork GP Training Programme Dr Paddy Ryan said “not alone was it an IR issue, but we were worried about a quality issue. We were really lost souls and [were] wondering how we could get our quality agenda back on the table.”

Assistant Programme Director with the Western Training Scheme Dr Pat Durcan said he had arrived in Dublin that morning “with despair, I genuinely did. I had despair about the future of GP training and I had despair about the future of the College.” He said he wanted to acknowledge Mr Foy for his “leadership” on the matter.

Dr Bertie Daly, Programme Director with the South West Training Scheme, said “we have been taken to the brink”. He said it was important that the College “openly divulge the sequence of affairs that led to that, the concerns, if they were real and legitimate, or whether they were imposed on them by the HSE, and that we find out what happened and ensure that doesn’t happen again”.

He said GP trainees had been “totally, totally disenfranchised by this process”. In recent weeks, trainee representatives have withdrawn from the College’s transfer implementation committee due to concerns that their views were not being heard.

Speaking to MI, Mr Foy said the transfer process was “just paused for the moment” until the IR issues are resolved. “So when they are resolved, our intention would be that we proceed to agree a SLA [service level agreement]; that SLA would be brought back to the members then for final sign-off.”

On whether the agreed funding arrangement was still in place, Mr Foy said “the overall funding is there and has been agreed but what we haven’t agreed is a final service level agreement”.

Mr Foy told MI the IR issues require resolution, as the College needs to know how many people will be “transferring across and once we know that, it is easier to deal with budgets and things like that”.

It is now likely that full implementation will not take place until 2019, according to Mr Foy. “At this time, partial implementation of the plan will not occur in July 2018.”

Regarding the programme directors, a separate structure to the College’s transfer implementation committee is being devised in the interim “to allow them participate in the plan”.

Regarding trainees potentially re-joining the transfer implementation committee, further meetings are to be held with trainees this month.

“The College were happy with the way the discussions were conducted and which led to the signing of the heads of agreement,” according to Mr Foy.

The ICGP Annual Conference, held over two days at the Convention Centre in Dublin, was the highest attended in its history, with over 450 members in attendance; double the number of the previous year.

“We had the highest numbers ever, we had some great sessions, some inspiring talks, and I think generally from speaking to people, it worked well,” Mr Foy told MI. “I am not too sure where we will go next year. I think it is good for general practice that we move it around.”

Government has ‘no idea’ of the depth of the GP manpower crisis — Harty

The Government has “no appreciation of the depth of the manpower crisis in general practice”, Independent Deputy Michael Harty told the ICGP Annual Conference.

Speaking from the floor during the College Forum on ‘Recruitment, Retention, Replacement’, Deputy Harty said the Government is aware there is a manpower crisis “but they don’t know the depth of it” and “have no idea what is coming down the line”.

 “The Department of Health doesn’t know what general practitioners do — they have no idea what GPs do. No idea whatsoever. The unwinding of FEMPI from a Government point of view is going to be on the basis of extra services over a three-year period — that is the present policy.”

He urged GP representative organisations to draw-up a multi-layered GP contract and present it to Government.

The conference heard that many GP practices are closed to new patients, adding to increasing pressure on out-of-hours services. Hundreds of GP retirements are looming and only around 380 GPs who hold a GMS contract are aged under 40. 

Monaghan GP Dr Illona Duffy said one of the reasons she chose general practice over a hospital-based specialty was its family-friendliness, but she said this had changed. She identified with the experiences of colleagues going into their practices at weekends to do hours of paperwork and “not being able to get home to see your kids to put them to bed”. 

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Dr Illona Duffy

Speaking to the Medical Independent (MI), Dr Harty said it was not feasible for GPs to take on extra workload in exchange for FEMPI reversal. “The number of patients who are eligible for medical services, GP services, has increased exponentially and the amount of work involved in looking after the ageing population has also increased, so that productivity has been built into what has happened over austerity.”

He told MI the Government sees GP numbers and concludes “there are more GPs now in the country with a GP contract than ever before; what they don’t realise is that many of those GPs are not full-time working equivalents… It is beginning to hit home now because last week, three TDs came up to me in the Dáil and said, ‘what the hell is going on in general practice?’”

He said constituents coming to TDs’ clinics are asking for help finding a GP.

Hospital trainees should have rotation in general practice, conference hears

Doctors who are training to be hospital specialists should undertake some of their training in the community, a professor of general practice told delegates at the ICGP Annual Conference.

Prof Liam Glynn, Professor of General Practice at University of Limerick Graduate Entry Medical School (UL GEMS), noted that GP trainees complete part of their training in hospitals. He said their colleagues in hospital-based specialties should also rotate into the community. Prof Glynn made his comments while delivering the Foundation Lecture, which was titled ‘The ‘Continuity’ Principle — General Practice as a Key Driver of Medical Education’.

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Prof Liam Glynn

“I think exposing our future consultants, our future hospital specialists, to what it is like to work as a generalist in the community can only be of benefit,” Prof Glynn told the Medical Independent (MI). “We know how powerful the community and general practice is as an educational context… but also so that they have that context when they become consultants — that would be really valuable.

“When you are training to be a GP, you spend some time in the hospital training there, so why isn’t the opposite happening, so that we can both appreciate each other’s contexts and surely that is going to lead to increased co-operation, increased collaboration and streamlining between primary and secondary care.”

During his lecture, Prof Glynn outlined the model of longitudinal integrated clerkship at UL GEMS. This requires medical students to spend a continuous period of 18 weeks in general practice. Prof Glynn said it promotes ownership of learning and an enhanced relationship with patients and supervisors.

“General practice is a powerful educational environment, so the question is, why do we give our students only two-to-four weeks of this stuff, in their entire medical careers? And a broader related question is, why do we give our students two-to-four weeks of anything when we know that this traditional small-block model of medical education does not work and may even be detrimental — in fact, there is a lot of evidence to show it is definitely detrimental to our students’ development,” he told delegates.

Deficit of treatment for alcohol-dependence in pregnancy

There is a dearth of treatment services available for alcohol-dependent pregnant women, a leading neonatologist has warned.

Speaking at a seminar on alcohol misuse at the ICGP Annual Conference, Dr Adrienne Foran, Consultant Neonatologist at the Rotunda Hospital, Dublin, said there is “really, really poor” availability of services for pregnant women who are abusing alcohol.

“There are no beds, there is nowhere to get them into, there are no fixed [dose] Librium programmes; a day in the Rotunda isn’t going to solve this… ” she noted.

Dr Foran said it is much easier to get women on methadone, heroin or cocaine into recovery during pregnancy compared to those with alcohol problems. She noted that opiate use in pregnancy has “gone down dramatically”.

Alcohol is a known teratogen and permanent damage can be done before a woman even knows she is pregnant, outlined Dr Foran.

According to Dr Foran, “even low levels of pre-natal exposure can have adverse effects on foetal development”. She said the safest approach is to advise patients to abstain from alcohol during pregnancy.

It has been estimated that 600 babies per year are born with some form of foetal alcohol syndrome (FAS) but Dr Foran said it is often difficult to diagnose.

Meanwhile, Consultant Gastroenterologist/Hepatologist at Beaumont Hospital, Prof Frank Murray, told the seminar that Ireland has an “urgent crisis” as a result of alcohol consumption. He said the average drinker is drinking over 14 litres of pure alcohol per year, which equates to 150 bottles of wine, or three bottles a week.

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Prof Frank Murray

Liver units are seeing people presenting with cirrhosis who had no warning symptoms and for whom “generally it is too late”. He said alcohol accounted for three deaths per day nationally and was associated with over 60 medical conditions, including many cancers.

Selling alcohol in every corner shop was “not a good idea” but there was “huge resistance” to change from “vested interests”. He said the link between sports sponsorship and alcohol must also cease.

Prof Murray described the Public Health (Alcohol) Bill as a radical piece of legislation. He foresees that minimum unit pricing will be the most effective of its measures.

During his presentation, he also alluded to his concerns over Ireland’s current low-risk limits for alcohol consumption.

Speaking afterwards to the Medical Independent (MI), he said Ireland requires an “evaluation” of  low-risk limits for alcohol consumption and he favours those adopted in the UK in early 2016.

In Ireland, the low-risk limit for men is 17 standard drinks per week and 11 standard drinks for women. In the UK, the equivalent limits are 11 for both sexes.

Prof Murray told MI he was not aware of any plan within the Department of Health to reassess the limits.

Around 80 patients used SATU secure storage option for forensic evidence

Over 800 patients were seen at six adult Sexual Assault Treatment Units (SATUs) in 2017 and around 80 took the option of secure storage of forensic evidence. This facility is available for people who are uncertain as to whether they wish to report the incident to An Garda Síochána.

Speaking at a seminar at the ICGP Annual Conference, Dr Maeve Eogan, Medical Director of National SATU Services, said there are six HSE-funded adult SATUs providing clinical, forensic and supportive care for those who have experienced sexual violence. The annual budget is €1.5 million, which Dr Eogan described as “insufficient”.

Each unit has a full-time clinical nurse/midwife specialist. However, “the aim is that we would have two or three in each unit because those nurse specialists do a lot of the day-to-day work”.

Dr Eogan added that “as with any health service, we are limited by infrastructure, we are shoehorned into small spaces in hospitals and clinical sites; we do hope to be considered for expansion in the context of other health service developments”.

The “aim is that each SATU is available 24 hours a day, seven days a week”. The adult services are for men and women over the age of 14 years.

Dr Eogan said clinical nurse/midwife specialists provide a permanent staff, “a consistent nine-to-five presence, and then we have a community of forensic medical examiners who have a range of professional backgrounds”.

She said there is no ‘typical victim’ of sexual violence. She said people’s actions and activities within the initial days after the incident “do generally frame their recovery, so somebody who reports early and gets healthcare as well as forensic care potentially gets better quicker”.

There are a “whole range” of medical and psychological sequelae, outlined Dr Eogan. The presence or absence of injuries does not generally confirm or refute the allegations made, she noted.

While not within her remit, Dr Eogan added there is a major shortfall in services for children.

“Because at this moment in Dublin, a four-year-old gets a worse service than a 24-year-old, and that is really not fair. There is a lot of impetus to try and improve that. Crumlin are working very hard — they have appointed a nurse specialist to lead that up and they are going to train a nurse on our new training programme in September.”

Gambling online ‘far more dangerous and addictive’ — expert

Online gambling is considered “far more” dangerous and addictive than traditional gambling forms, an addiction specialist told GPs at the ICGP Annual Conference in Dublin on 26 May.

Mr Barry Grant, an addiction counsellor and CEO of Problem Gambling Ireland, said smartphones have the “capacity to dispense potentially addictive gambling products 24 hours a day, 365 days a year”.

He said this is being reflected in presentations from people with gambling problems. “Certainly, in our organisation and in my private practice, a huge amount of the people who present with gambling problems are doing it on their smartphone or doing it on their laptop at four or five o’clock in the morning, chasing their losses, so online gambling is extremely dangerous… ”

Ireland has the highest number of online gamblers per capita in the world. However, there are no definitive statistics on the number of problem gamblers in Ireland, outlined Mr Grant. In 2010, the Institute of Public Health estimated that between 0.6 per cent and 1 per cent of the Irish population had a gambling problem, or up to 40,000 people. However, based on a subsequent study in Northern Ireland, which reported 2.3 per cent prevalence, Mr Grant would put the figure at up to 100,000.

The numbers “would appear to be increasing” and for every problem gambler, it is estimated that an additional eight-to-10 people are affected by gambling-related harm.

“In Ireland, men would be considered four times more likely to develop a gambling addiction than women, although more and more women are developing gambling problems. Adolescent gambling, according to the Institute of Public Health, is two-to-three times that of adults and studies have shown that a person who begins gambling in adolescence is far more likely to develop a gambling addiction than someone who starts in adulthood.”

In DSM-5, published in 2013, pathological gambling was renamed as ‘gambling disorder’ and characterised under the substance-related and addictive disorders.

“That was a big change. They realised if you put someone into a functional MRI machine and you get them to play a gambling-type game when they are in it, the same parts of the brain light-up for the person with a gambling problem as light-up when taking a line of cocaine or another stimulant drug.

“So, they moved it from impulse control disorders into the addictions. Hopefully, that may improve treatment coverage, diagnostic accuracy and screening efforts. Unfortunately, if anyone has ever looked at the HSE Service Plan, the word ‘gambling’ does not appear in it, so we are a little bit away from seeing that improvement in treatment coverage and it does impact the referral pathways you might have as GPs.”

Mr Grant referred to useful screening tools that can be used in general practice, such as the Lie/Bet Screening Tool.

He also drew attention to the fact that some medications are linked to the onset of problem gambling.

“Medications — for example, Levodopa — used in the treatment of Parkinson’s and restless leg have been strongly linked to the onset of problem gambling. According to the Parkinson’s Association of Ireland, approximately 17 per cent of people on dopamine agonists have some form of impulse control disorder and 7 per cent of people [are] on Levodopa. One large US study found that approximately 14 per cent of Parkinson’s disease patients experienced at least one impulse control disorder.”

Mr Grant said that only 1-to-5 per cent of people with a gambling problem seek help and just 1 per cent receive treatment. The stigma around the addiction is “massive,” he stated.

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