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It was telling that both executive heads of the IMO and NAGP travelled the long, winding and scenic roads to Clifden, Co Galway, recently to attend the Annual Conference of Rural, Island and Dispensing Doctors. As general practice approaches yet another crucial juncture, there is clearly a battle for hearts and minds — and optics matter.
Comments by GPs from the floor and in private were suggestive of many long roads ahead. The realisation of a working relationship between the two organisations, and of a new GP contract, still appear as a mirage on a distant horizon, and there are growing fears of a ‘divide and conquer’ approach from the State.
In August, Minister for Health Simon Harris announced that the NAGP had been invited to join the GMS contract talks and his intention to hold a primary care stakeholder conference. At press time, there was no date available as to the recommencement of GP contract talks, nor as to when the stakeholder conference would take place.
Speaking to the Medical Independent (MI) at the Clifden conference, Independent TD Dr Michael Harty warned that Minister Harris is not interested in refereeing the two unions.
Co Mayo GP and former IMO President Dr Ken Egan plainly described the macro context, referring to both unions as “businesses” that are keen to ensure their own survival and growth.
One GP told MI there is a sense in the IMO that the NAGP is ‘stealing their clothes’. Indeed, the IMO undertook an almighty fight to get to the negotiation table, including a legal battle with the Competition Authority, which cost the IMO €1.2 million before it was settled.
There is major scepticism about the NAGP’s claim of over 1,700 members, according to another GP, who is a prominent member of the IMO. However, this GP disputed that IMO members roundly disliked personalities in the NAGP. They added that they understood why some GPs left the Organisation to join the NAGP, in the wake of the McNeice pension controversy: “What happened in 2012 was catastrophic and terrible.” The IMO, for its part, has declined to reveal its current GP member numbers.
There is persisting irritation among leading IMO members about what they regard as the ‘scuppering’ of a potential deal with the HSE/Department of Health on distance codes earlier this year. The IMO says the NAGP publicly welcomed an unfinalised rural practice agreement and distance codes disappeared from negotiations. The NAGP, which has not been involved in GP contract negotiations to date, disputed that distance codes were ever on the table.
IMO GP Committee Chair Dr Padraig McGarry and GP Committee member Dr Martin Daly both spoke on the issue in exasperated tones, with Dr McGarry remarking how the turn of events, as he saw it, “sticks in my craw”.
“Distance codes went off the table that day, not to come back; it was thrown into the FEMPI process and there were other particular STCs that were particularly important to rural practice — they disappeared off the table, never to come back,” said Dr McGarry at the rural doctors conference.
NAGP National Council member and occasional MI columnist Dr Lucia Gannon spoke for many, judging from the applause, when she signalled the need to move on from this debacle. “Martin,” she said following Dr Daly’s comments on the issue, “you might say the NAGP is responsible for scuppering the distance coding. I am not so sure about that; I don’t agree with you. Even if it is true, in your perspective if it is true, if that is what happened, can you forget about it? Can you put it behind you, can you move forward? We have had to put lots and lots and lots of things behind us with regard to our negotiating bodies and we have done it… ”
From the podium, Dr McGarry remarked that unconscionable things had been said about people in the IMO, generating a profound lack of trust. However, in the absence of providing any substantive detail as to the source and subject matter of these alleged statements, it was difficult to find fault with one GP’s summation from the floor that it thus amounted to “hearsay”.
Throughout proceedings, Dr McGarry positioned the IMO as worldly veterans of State obfuscation and prevarication to the NAGP’s innocent ‘new kid on the block’.
He pointed to the IMO’s success in respect of the Rural Practice Support Framework and revised list of special items of service.
“Does this solve the problems for rural practice? No, but it is a start. We haven’t been trumpeting the achievement — it is what we do, and we’ve been doing this for 30 years.”
The IMO, he underlined, “will not allow new, uncontracted work to become normal workload under the existing contract”. He said the HSE and Department “have a history of encouraging this”.
Dr McGarry warned that the Community Healthcare Organisations (CHOs) are a mechanism to transfer workload from secondary care to general practice without resourcing. Once work becomes “normal general practice”, there will be “no further negotiation” on those duties.
“Unfortunately, GPs, perhaps it is our weakness and it is our strength — we have a history of working over and above what our contractual arrangements are, and it is that vocational approach that has probably led us into general practice in the first place, but it is the very weakness that the Department of Health and the HSE will exploit.”
But Dr McGarry’s most telling remark concerned his belief that the State is not keen on realising a new GP contract at present, and is content to ‘kick the can down the road’.
“The IMO has serious concerns about the tactics of the Government; there is no meaningful engagement, no real resources and unfortunately in the current economic climate, they are not going to be able to deliver a full contract with all bells and whistles because, to me, the resources are not there. Since the Brexit debacle, I think the fiscal space has narrowed… ”
However, Dr McGarry continued: “We do need to continue with the Memorandum of Understanding and plan for a number of years of committed, ring-fenced funding for general practice with ongoing developments. The Memorandum is in place; it should be followed.”
Dr McGarry also insisted that the IMO has a positive approach, having developed significant papers on matters such as a multimorbidity model, urban and rural deprivation in general practice, nursing home workload, out-of-hours and end-of-life care, in preparation for contract talks.
Speaking afterwards to MI and also at the IMO’s pre-Budget briefing in Dublin some days later, Dr McGarry declined to comment conclusively on the possibility of negotiating alongside the NAGP.
At the latter briefing, in response to questions from MI, Dr McGarry said: “We have different policy views”. The IMO would not take on any unresourced work prior to resourcing, “which might be different to other organisations”.
He added: “We certainly haven’t got a mandate from our members to enter negotiations alongside another organisation… Until we actually know that there are negotiations going to go ahead, I think we’ll just reserve our position.”
Dr Daly, expressing his personal views to MI, echoed Dr McGarry’s points. The IMO and NAGP are “two separate organisations with different mandates”. The IMO has a consistent, coherent, strategic approach, he contended.
However, as recently revealed by MI, the NAGP has written to the IMO seeking a meeting before the recommencement of GMS talks, in an effort to find common ground, and has publicly said on a number of occasions that it is happy to work together with the IMO.
Meanwhile, NAGP CEO Mr Chris Goodey received praise from IMO stalwart Dr Egan at the rural doctors’ conference, with the Co Mayo GP complimenting his PR skills and work rate.
Mr Goodey has done “tremendous work achieving publicity for GPs… fair play to him, he has worked hard to improve things for us”.
Nevertheless, Dr Egan described the IMO’s Chief Operating Officer (COO) Ms Susan Clyne as “the best and most experienced negotiator there is in the business of general practice at the moment”. The NAGP is currently in the process of hiring its own professional negotiator for the contract talks, as recently reported by MI.
Mr Goodey revealed at the conference that he had told IMO members that if he was “the problem”, he would walk away. He said he had been working 70-to-80-hour weeks and also emphasised that his salary of approximately €120,000 per year is well documented (the IMO does not publish the salary details of its COO). The proposal of walking away was met with a muted reaction. This remark was made in the context of the IMO’s belief that Mr Goodey allegedly scuppered a potential deal on distance codes, it is understood.
Mr Goodey told MI: “The general consensus from all stakeholders and advisors into the 10-year strategy is that we need a GP-led primary care system, but there is no way we are going to get that if we’ve got a split in general practice, if you can’t get some level of co-operation.”
The NAGP CEO also denied that the Association would be advocating any extra GP workload without resourcing. The NAGP is on record as supporting GP participation in CHO meetings, in order to facilitate discussion and an exchange of views.
“Basically, our position is that communication with the HSE is a positive thing. And there is only one way you are going to be able to influence budget and how services are delivered — through communication and by having GPs in key positions within community health organisations… so we would support the appointment of GP leads… ”
However, the NAGP is “on the same page” with the IMO on there being “no possible way GPs can take on any more work without a new contract, where they are already bursting at the seams.
“But by communicating with the HSE to explain that… I don’t see that as a negative. I see that as a positive, as then they get to understand the problems that are in general practice.”
Mr Goodey revealed that NAGP nationwide consultations with GPs suggest that most believe there should be separate contracts for daytime and out-of-hours.
“In this day and age, from a personal perspective, I think it is insanity that we have a working time directive from Europe but we are having GPs having to cover 365 days a year and 24/7. It is lunacy and unsafe.”