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GPs positive, but fear risk of ‘unresourced’ work

By Paul Mulholland - 22nd Apr 2024

‘unresourced’

Paul Mulholland reports on the IMO AGM’s national GP meeting and speaks to the Organisation’s
new President, Dr Denis McCauley, about the issues facing the specialty

During the national GP meeting at the IMO AGM in Killarney on 6 April, Storm Kathleen was raging outside. The weather was not reflective of the mood in The Europe Hotel’s main conference hall where the meeting was held. In his opening remarks, new IMO President Dr Denis McCauley described how GPs were, for the moment at least, relatively “content”.

This was not a description that could be used at last year’s AGM. At that time, there was tremendous uncertainty among the group. The Government’s plans to increase eligibility for free GP care to all children aged six and seven, as well as on the basis of income, were criticised for not taking into account the existing capacity constraints within general practice.

However, shortly after the 2023 AGM, an agreement between the IMO and the Government was announced. The deal established various supports for GPs. It allowed them to hire more staff, along with fee adjustments, to accommodate the anticipated increase in service demand. In total, the financial package amounted to around €130 million annually.

Other positive developments have occurred over the past 12 months, such as an increase in the number of training places. The planned increase of 350 new-entrant places for GP training, which was due to occur in 2026, has been brought forward to this year. In his speech at the AGM on 5 April, Minister for Health Stephen Donnelly said additional training places and “the big increase in new GPs is making a difference”.

“In fact, for every GP who retires, there are now two GPs entering practice,” according to the Minister.

He also highlighted how there was “record demand” for these places.

“This year more than 1,300 doctors applied to start GP training, which is a record number, reflecting growing confidence in the future of general practice,” Minister Donnelly told the conference.

Positivity

Chair of the IMO GP committee Dr Tadhg Crowley agrees that there is a positive mood among GPs, fueled largely by last year’s agreement.

“We were very happy with the deal in terms of the supports,” Dr Crowley told MI.

Dr Crowley said the agreement has facilitated the expansion of GP teams and allowed GPs to “compete in a very competitive market to attract allied health professionals to come into general practice”. However, he said it was important to examine the reported low take-up of the means-tested GP visit cards and address any obstacles in the application process.

IMO GP committee member Dr Austin Byrne said it should be noted that there have been improvements within the specialty over the last number of years.

“As we have come out of Covid, I think we have a viable, sustainable, resourced, well-demarcated contract,” Dr Byrne told MI.

“GPs are satisfied. There have been a lot of positive strides. Certainty has been brought to the GP workforce. People feel that they can trust in their contract. There has been enhanced quality-of-care for patients. So there is a good degree of satisfaction. But we are keen not to become complacent on top of that.”


As we have come out of Covid, I think we have a viable, sustainable, resourced, well-demarcated contract

He cited the success of the structured chronic disease management programme as an example of the recent progression.

“We are really, really happy with it,” Dr Byrne said, pointing to the high level of uptake, with 97 per cent of GPs signing up.

“It’s equitable, it’s fair, it’s resourced, it’s quality care, it’s delivering for patients. And it’s allowing GPs to expand and enhance their level of service. It has a feel-good factor attached to it.”

‘Unresourced’ work

However, concerns remain. One key issue that was reiterated throughout the national meeting was the danger of ‘unresourced’ work and ‘mission creep’.

A motion was passed at the meeting on the issue. The motion stated: “While acknowledging the HSE funding, through the ICGP, for GP Clinical Leads and the value of that engagement, the IMO opposes the introduction of any clinical programmes in general practice that are not resourced or negotiated with the IMO.”

“Clinical care programmes, such as those negotiated between the IMO and the HSE, require specific resource allocation and it is unacceptable that significant additional workload would be imposed on GPs without negotiation and resources.”

Speaking about the motion, Dr Byrne pointed out to MI that Ireland’s ageing population means it is inevitable that the workload of GPs will increase in the near future.

“There will also be a growing scope of care across disease entities over the next decade,” he said.

“What we do for Patient A won’t look the same in 10 years as it does today. And we are just acutely conscious that, as our contract matures, we continue to review items of care within the contract. And as new services are earmarked for GP roll-out that it is done in a planned, resourced manner, as opposed to having a situation where HSE clinical care programmes start to change usual items of care.”

In his presentation to the meeting, Dr Byrne referred to recent ICGP documents on new care pathways for specific conditions or areas, such as menopause.

“The GP herd as a whole are not in a position to adopt those care pathways because we simply aren’t funded to do it,” Dr Byrne said.

“And the point was, if we want to have a menopause care pathway, we need to plan it in such a way that can be delivered by the majority of GPs, and that they are structured and resourced to deliver it, as opposed to having a group of niche GPs delivering a certain pathway of their own making.”

He said there is the risk that sub-specialists within general practice define pathways that cannot be realistically delivered under the current contract. 

“We need sub-specialists to lead the way,” Dr Byrne said.

“People with a special interest in particular areas are the right people to write guidance documents. But where we are trying to advance a pathway of care within general practice, where a sub-specialist is involved in developing that pathway before it is deployed among GPs, it needs to be stress-tested for deliverability by the average GP; it needs to be resourced.”

He said rolling out new models of care in a “piecemeal” fashion will result in “a very disparate group of services being provided by GPs”.

Dr Byrne’s presentation also referenced the new educational resources for GPs in the area of fertility published by the ICGP last month. The quick reference guide (QRG) on fertility assessment was launched alongside another QRG on contraception management in general practice. The QRGs provide extensive guidance to GPs in these areas in line with the women’s health taskforce recommendations.

Dr Byrne contended that although the fertility document exemplifies high-quality care guidance, the services it describes are not typically provided by the average GP.

“It provides a good set of outlines for what the College would like to achieve,” Dr Byrne argued. “And the point is, that is currently not within the contract.”


When a guideline comes out, it has to be relevant to the specialty

Speaking on the concern, Dr Crowley said: “One of the big fears is if more and more work comes that’s unresourced, we are going to be in the same situation we were 10 years ago.”

Medico-legal

For Dr McCauley, a GP based in Donegal, the reversal of FEMPI, negotiated by the IMO, engendered a new feeling of positivity within the specialty, which was built upon by last year’s agreement. However, despite his comments to the national meeting that GPs were content, he told MI that general practice was busier than ever. He said while the agreement for additional supports was welcome, the capacity of GPs to roll-out additional ‘free’ services is limited. In this context, Dr McCauley argued that there is the risk that new guidelines could create unsustainable workload pressures. Also, he said there is the potential for them to cause medico-legal issues. This is a theme that he examined in an article in the previous edition of MI and spoke about again in his closing address to the conference (see panel).

“If I go in front of a barrister in a court case and I didn’t follow a guideline, which I had no input into, which has no relevance to my profession, but is now published, it would put me at a disadvantage,” he told this newspaper.

Dr McCauley said it is essential that any new guideline is relevant to the majority of GPs. He argued that guidelines that go beyond what is practical for the average GP to follow can be “dangerous”.

“Because the expectation is set on paper… then the GPs are practising medicine that they don’t really believe in, but are having to do because that guidance is there. There is danger in guidance, generally…. When a guideline comes out, it has to be relevant to the specialty, and not just someone who has a particular interest in the area, but to the regular punter GP like myself.”

ICGP

Dr McCauley stressed there was a good relationship between the IMO and the ICGP, and that most GPs were members of both organisations. Regular meetings between the Organisation and College occur, he said. Dr McCauley also highlighted the collaboration between the two bodies during the Covid-19 pandemic.

In the development of new guidelines, Dr McCauley said it was important that rank-and-file GPs are consulted, in both the ICGP and the IMO.

“I always say, as with any organisation, before the genesis of any guideline, that [the ICGP] talks to their own common punter members first, and then they also talk to us. Then before they even publish a guideline to go through the same process and then there will be no issue.”

Strategic review

During the national GP meeting, a motion was passed calling on the Department of Health to set out a “clear timeline for engagement on and completion of the strategic review of general practice”.

This would “enable the commencement of negotiation on new contractual provisions for GPs”.

Another motion was on the subject of continuity of care. It stated: “The IMO calls on the Department of Health and the HSE to acknowledge the overwhelming evidence that continuity of care through general practice delivers better health outcomes for patients and to ensure that continuity of care is embedded into all relevant policy decisions so as to avoid the risks associated with fragmented care.”

MI asked Dr McCauley what outcomes he would like to see come from the strategic review. In response, he said it was important that the review recognises that the strengths of general practice need to be maintained.

“With healthcare, we are the gatekeepers in the country; we work through a particular type of practice, a thing called diagnostic uncertainty,” according to Dr McCauley.

“We manage risk very well…. I think any strategic review needs to make sure that that part of general practice is retained and that any new additional services we’ve been asked to do, any further responsibilities, can never be accepted if they put those principles of continuity of care and gatekeeping at risk.”

Acute service could collapse due to ‘legally induced demand’ – IMO President

In his closing address to the IMO AGM, the Organisation’s new President Dr Denis McCauley said existing medical negligence litigation was having a “detrimental effect” on how doctors practise medicine in Ireland.

“Medical negligence is proven when a doctor deviates from the standard which is actually applied by competent professionals of similar specialty in an area,” Dr McCauley said.

“But case law is moving beyond that. In Dunne v The National Maternity Ward 1989, it was found that even if a doctor is shown to have followed the standard practice that a competent professional would apply, negligence may still apply if ‘a plaintiff can establish that such a practice has inherent defects’.”

 Dr McCauley said legal practitioners and the judiciary which assess these cases must fully understand the models of care which each specialty follow.

“They must recognise in a hospital setting that the clinical staff are essentially working with one hand tied behind their back due to staff shortages and infrastructural deficiencies.

 “A failure to do this is leading to Ireland being an outlier in medical litigation; it is encouraging the exodus of well-trained competent medical staff from our shores to other health systems where this is not an issue. More importantly it is leading to altered patterns of medical practice which is leading to increased investigations and referrals from primary care to a secondary service that will soon collapse under this
legally induced demand.”

In his speech, Dr McCauley also referred to how shortages of beds, consultants, and GPs have led to waiting lists, which are “frighteningly long”.

He highlighted how the Economic Social and Research Institute estimates that thousands of new beds are required in public hospitals.

“Absent those extra beds, our bed occupancy rates run at 88 per cent (11 per cent over the recommended upper limit) and our full capacity protocols are now often operative year-round.”

Speaking to the Medical Independent, Dr McCauley said that during an election healthcare can be “a political football”. And, he added, for politicians developing a ‘free’ service is sometimes seen as more attractive than addressing capacity issues.

“There’s no votes in it,” Dr McCauley said.

“Often [politicians] don’t get the chance to stand outside the hospital and cut the ribbon when new beds are put in because of the election cycle being so short. But if we don’t get beds, the capacity shortages won’t be addressed.”

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