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No country for GPs

Dr Pierce Molony retired from his practice in Johnstown Bridge, Co Meath, last week. He felt disenchanted, tired, and defeated, against a backdrop of successive FEMPI cuts, an indifferent bureaucratic HSE and a full-blown GP manpower crisis. It is a story sadly familiar to many GPs across Ireland, and is now generating some political interest.

But it wasn’t supposed to be like this. Qualifying in 1974, Dr Molony was appointed to his practice by the Eastern Health Board in 1984 following five years in hospitals in Dublin and abroad and five years in general practice in North Tipperary. He was looking forward to a future in a vibrant, developing specialty and certainly did not imagine his exhausting, troubled final years before retirement.

“In 1984, the list was advertised as having 250 patients; small, but I was glad to get it. About 15 others applied, a reflection of the plentiful supply of doctors at the time. In my early weeks, I discovered there were only 136 people still alive of the 250 on the list. I doubt this was deliberate misinformation, but it highlighted a dysfunctional system,” he tells the Medical Independent (MI).

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Dr Pierce Molony

Slowly, his GMS list increased to 700 by 2009 and to 1,150 by 2012, reflecting the significant increase in medical cards during the recession.

“Prior to the Celtic Tiger, this area was very rural, consisting of small villages and small farms derived from land-commission divisions. I was able to develop a private practice, non-existent at the beginning. It is an area with lots of lovely, resourceful country people within 30 miles of Dublin that has been overlooked for development. Most of the existing small industries closed or downsized over the years, but the arrival of IT-related industries has helped increase the population hugely.”

Like many rural practitioners, Dr Molony developed his practice into a ‘one-stop shop’, providing a wide range of medical services for patients. His tradition was to try to keep his patients away from hospitals as much as possible while still practising defensive medicine, aiming to provide as much care in the community as possible, long before this idea became the current HSE catchphrase.

“My desire was to practise medicine on the basis that it was an ordeal and effort for a patient to visit a doctor, in the same way as it is an ordeal for me to attend my dentist, and I should try to get as much into any one consultation as possible,” he says.

“When I started, there was no easy access to laboratory services. My wife was usually the courier, detouring on her way to work. ESRs and microscopy for urines were done in the practice. Out-of-hours cover was not shared until 1990, when colleagues put together a cross-cover arrangement. On-call weekends were flat out, sometimes up all night, no mobile phones. Co-op services started in 2001 and mobile phones were commonplace. With this came a Health Board-sponsored collection for lab samples, a God-send. There was always restricted access to radiology services, but Naas Hospital was most helpful in this regard. My co-op was based 25 miles away in Navan; bad roads on winter nights for patients to traverse and for the doctor to get to and get home after midnight.”

Retirement plans

At the time of closing, Dr Molony’s practice was a 2.5-to-three doctor practice and he paid redundancy to his staff.

“Between 2012 and 2014, three GPs worked here; on average one patient a day was joining the practice. I was the principal and one of the other two, Dr Aifric Boylan, applied and got a GMS number. She would become principal and, aged 63, I would step back gradually.”

However, life in practice became more difficult. Dr Molony cites the problems of dealing with the bureaucratic and unhelpful HSE, the impact of successive FEMPI cuts to GP practice incomes, the failure of Government to recognise the need to invest in general practice in any meaningful way and “the regular whine from elected representatives, nationwide, about ‘the failure’ of GP services”.

“There is insufficient recognition of the high costs to GPs in running a practice. Without investment, services deteriorate. Aifric Boylan could see no future for GPs in Ireland and, two years ago, rightly left for Australia. I reverted to working 60 hours a week, with my other colleague increasing to 40 hours a week. I am now 66 years old and have started to accumu late health issues and must stop my 60-hour weeks.

“Since 1 December 2015, I have engaged with GPs-in-training in the hope of attracting a principal to this practice. I have failed. I advertised internationally in June and July. I got three replies, one each from India, Bulgaria and Romania, none yet registered with the Medical Council and all wanting to be employed by me!”

Political spin

He also finds it galling to hear it stated that more GPs than ever are registered with the Medical Council, but it is rarely mentioned how many of these are working part-time, or indeed working at all.

“The same applies to GPs with a GMS registration number. Some are registered only for cervical smears, but have no responsibility for GMS patients. Are they included in the number of GPs with a GMS number? No-one knows; there is always spin.”

Like many of his colleagues, Dr Molony feels the free GP care for under-sixes scheme was the straw that broke the camel’s back.

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Dr Pierce Molony with Deputy James Lawless, Fianna Fáil TD for Kildare North, at Johnstown Bridge Health Centre

“In particular, the first draft of the under-sixes contract was instrumental in focusing my mind on retiring. In my opinion, this draft was designed to scare and bully GPs and was not a platform for engagement. It denigrated GPs and precipitated an acceleration of the exodus abroad. The under-sixes contract, as it now exists, is a political stroke and HSE ‘achievement’. It has destabilised general practice, with no attention being paid to the problems it causes, especially to daytime GP waiting times and out-of-hours service delays and to A&E queues. I did not sign it. Nevertheless, I applaud the concept of free GP care for all, provided it is resourced correctly and negotiated by parties with mutual respect — conditions that I do not observe even now.

“I believe that this has come to pass because of the abusive way Irish Governments are citing competition law as an excuse for refusing to discuss fees with GP representatives. It amounts to an abuse of office and an abuse of a dominant position by the Government and HSE. This has been a significant factor in the GP exodus and to my being unable to attract a GP to a thriving practice less than 30 miles from the centre of Dublin.”

Lack of resources

So what does Dr Molony feel is so wrong with the healthcare system in Ireland?

“Administration absorbs far too great a percentage of the available resources. Three per cent of the health budget goes into primary care. In the UK, this is 9 per cent, rising to 11 per cent shortly,” he comments.

“FEMPI was excessively unfair to GPs. Practice income was cut, rather than just our personal income. Nonetheless, I maintained practice services until the time came to replace equipment. Audiology, ECG, 24-hour blood pressure and ultrasound equipment could not be replaced when they failed. The result? An increase in referrals to outpatients, ancillary services and A&E.

“I feel the future of general practice and secondary care in Ireland is hopeless. The HSE gets bigger, with more directors/managers, while phones ring out unanswered and service to the public diminishes. There are longer outpatient waiting lists, with less satisfactory outcomes for patients. I receive more complaints about poor-quality interaction with secondary services and experience greater difficulty in making phone-calls to sort out these matters,” he says.

“Despite this, I appreciate the great efforts made by many consultants to bridge the gaps between primary and secondary care.

“Increasingly, GPs are closing their lists to new patients. It is with great regret that my practice has felt it necessary to refuse 300 or so persons in the past two years in order maintain safety standards for existing patients.”

 And what now of his busy practice and his patients?

“A locum has been appointed to my practice. The hours offered through the HSE, as per HSE notification to my GMS patients, are 24 hours a week, compared to the 100 hours a week offered by my practice now. I imagine this will impact on secondary care, including A&E.”

Letters, emails and tweets on this topic are welcome: Priscilla@mindo.ie or Priscilla Lynch, Editor, Medical Independent, 7 Upper Leeson Street, Dublin 4.

  1. DECLAN LARKIN on September 10, 2016 at 5:20 am

    Pierce, I am with you 100%. I am an Irish GP too and identify with you analysis to a “T”.
    The abuse by our HSE overlords has been dismaying and saddening.
    ‘You reap what you sow’ and the GOV has been willfully sowing the destruction of Irish GP for many years now – e.g. the removal of distance codes / slashing of GMS cards / refusal of new contract / brinkmanship with young Dr’s unable to hold off signing the U6’s etc for fear of their practices going to the wall / the huge annual spend on anti GP/Dr media campaigns ………. It goes on ad nauseum.
    Wanton neglect. Unkept promises etc etc
    You are so “on the button”.
    The Gov seems to think that they will do better with an emasculated professional rank. Any hint of a “win/win” strategy is avoided at all costs. BREAK THEM seems to be their mantra. Well and good, but remember that when you get what you wish for you not like the outcome[s].
    GP as traditionally practiced and revered by our patients is dead.
    When history looks back on what they have destroyed there will be some amazement that a tradition so admired could be so callously treated and critically damaged, esp. when most developed countries currently are trying to attract GPs rather than damage them, their health and financial independence/retirablility [if you can accept my newly concocted term]. It seems that not alone will you be welcome to slave away until your mid-70’s but the HSE is apparently in contemplation of “open-ended” contracts for GPs. When I heard that I thought…. Right.
    I have committed by life to Irish General Practice. Like Dr Molony aspiring to provide the best care I can and extra services to keep patients happy and out of the overloaded hospital system.
    ‘Nuff said…!
    I am writing this from a foreign country.
    Here, purely to try an assure my wife and children of a husband/father and [Please God] future grandfather that has not worked himself into ill health and a premature grave.

  2. pmoloneyquinn on September 5, 2016 at 12:58 pm

    So sadly right. I found myself in similar position in 2001 -2005 when the HSE turned its corporate back on me and my practice not to mention my patients. I became acutely ill and received little help with regards to locum cover, costs etc…
    This resulted in my early retirement and financial distress ++ and patients assigned to other practice lists without discussion.
    This is no country for GPs

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