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With the planned extension of free GP care, pressure in out-of-hours services and big changes in GP politics, David Lynch takes a look at the state of play in primary care
“I think the NAGP [National Association of General Practitioners] is dead, and I don’t see how it can be resurrected.”
That is according to Clare TD Dr Michael Harty, who is Chair of the Oireachtas Committee on Health. Dr Harty voiced scepticism to this newspaper over the recent deal between what remains of the NAGP, in the form of the Alliance of Family Doctors (AFD), and the trade union Unite.
The narrative of the recent big changes in medical politics will be well known to most GPs.
In late April, the then NAGP President Dr Maitiú Ó Tuathail and the entire national council resigned due to serious concerns about the Association’s “internal governance”.
Soon afterwards, in May, the NAGP entered into voluntary liquidation.
While the ‘business’ section of the NAGP went into liquidation, the trade union element (the AFD) entered talks with Unite to negotiate a deal to allow the union to represent GPs in the future.
In late August, the Medical Independent (MI) reported that those talks were completed and as a result, Unite would form a GP branch if enough doctors join.
Separately, a recent story in The Sunday Business Post (22 September) reported that the Office of the Director of Corporate Enforcement (ODCE) was investigating matters that took place during the lifetime of the NAGP.
When contacted by MI, a spokesperson for the ODCE told this newspaper:“The ODCE does not comment on individual cases and, accordingly, I am unable to confirm whether or not there is an investigation being conducted or provide any of the other information requested.”
This newspaper sent a number of questions regarding the NAGP to the Association’s former CEO Mr Chris Goodey. He replied that he could not “comment as I am taking appropriate legal advice regarding defamation”.
With the complicated legacy of the NAGP still unresolved, Unite is now recruiting GP members.
But does an appetite exist for another trade union group to represent GPs?
There are mixed signals. At its height, the NAGP boasted more than 2,000 members and in June, this newspaper reported on a poll, which ran on the National GP Forum, and showed a majority of respondents voting ‘yes’ to the need for a ‘GP-only’ trade union.
However, as of 20 September, the Unite union had yet to reach the 50 GP members it needed to establish its GP branch.
“That is true, 50 is the number,” Mr Brendan Ogle, Republic of Ireland Senior Officer for Unite, told MI.
“We would be approaching that number now but have not taken the formal steps necessary to establish the branch yet.”
Asked what was the first issue that Unite will highlight in general practice, Mr Ogle said it would be a matter “entirely” for the future branch. He added that Unite had yet to approach the Government to organise meetings on general practice issues.
Mr Ogle said “it’s probably too early to say” what the reaction of GPs has been to the AFD-Unite agreement.
“It is entirely a matter for GPs to decide if they wish to organise within Unite on the basis offered to improve their ability to organise and advocate for themselves and their patients. We are here to support if sufficient numbers wish us to. Assessment of this matter is ongoing.”
However, there was a mixed response to the AFD-Unite agreement with the GPs that we talked to.
At the time of the late August announcement of the deal between the AFD and Unite, Dr Andrew Jordan, ex-Chairman of the NAGP, told MI that it was a “positive move for the future of general practice”.
He said this was because at the present moment, there are serious problems in general practice, particularly in rural general practice, that need to be fixed… Whatever has been done to date has not sorted it out.”
However, other GPs contacted by this newspaper seem less sure.
Dr Harty voiced his sadness at the collapse of the NAGP, of which he was a member, and his own doubts about the Unite move.
“I think the concept of an organisation which specifically represented GPs and puts an alternative view forward was very positive,” Dr Harty told MI.
“The NAGP certainly stimulated debate in relation to the future of Irish general practice and it gave an alternative point of view. I was very disappointed in the manner in which the NAGP finished… with the lack of proper governance, structures and lack of proper oversight.
“The demise of the NAGP in the manner that it happened — I felt let down by it really, and very disappointed.”
Looking back, Dr Harty said: “Getting a negotiating license from the Department [of Health] proved extremely difficult.”
However, the AFD joining-up with Unite does not excite Dr Harty.
“Now, hitching your wagon, if you like, to an existing trade union [Unite], which may not have the necessary understanding or the ability to negotiate effectively for GPs,” he said, “I don’t think it is a good idea.
“I think the NAGP is dead, and I don’t see how it can be resurrected.”
Former NAGP President and Dublin-based GP Dr Ó Tuathail told this newspaper in June that he was “personally gutted” by the demise of the Association.
However, speaking more recently on the Unite deal, he said: “I am not a member of either organisation [AFD or Unite]. I’m not involved in medical politics [since] April. I am not privy to what the agreement is; I just don’t know anything about it.
“Do I think it is a good idea? I just don’t know enough to be able to comment on it. I don’t know about Unite as a trade union; I don’t know about the Association of Family Doctors as a trade union.
“At the moment, it remains unclear,” he told MI.
However, in terms of his general experience with the NAGP, are there any lessons he would take when it comes to trade union representation?
“Speaking very broadly, the issue with the NAGP [was that] all the GPs involved did so much on a voluntary basis without payment and did so basically, out of their own time,” recalled Dr Ó Tuathail.
“That is a huge sacrifice. It’s kind of difficult. The year I did [as President] I would have taken, certainly towards the end of it, two days off a week unpaid to work.
“That is not sustainable, to work for a union on a voluntary unpaid basis, and that takes its toll, financially, but personally as well… If you look at other unions, like Unite or the IMO, they have a huge secretariat who do a lot of the work that a lot of GPs did for the NAGP on a voluntary basis.
“I suppose looking at it again from the outside, the greatest difficulty the NAGP had was that its own GP council did a lot of the work that a secretariat would do, and that is just totally unsustainable.”
Perhaps unsurprisingly, the current President of the IMO and Longford GP Dr Padraig McGarry did not seem hugely enthused by the AFD-Unite deal.
“Normally, I wouldn’t comment on the business of other groupings,” Dr McGarry told MI.
“My knowledge of the Unite trade union would be pretty much based solely on newspaper articles.”
Dr McGarry noted an article in this newspaper last month which highlighted that Unite clarified that it will not be able to represent GPs in respect of employment contracts unless 80 per cent of GPs in Ireland join the union.
“My recollection of that article was that it seemed to cast doubt on the ability of Unite to represent doctors on contracts in respect of employment matters,” said Dr McGarry.
On the choice facing GPs of whether to join Unite, Dr McGarry said “doctors need to make their own decisions on such matters”.
“They need to make their decision in a business-like manner.
“They can decide to align themselves with Unite, or maybe they can choose an organisation such as the IMO? An organisation who has a Framework Agreement, which allows the IMO to negotiate terms and conditions, including remuneration for its members in all public contracts.
“[The IMO] has a secretariat available to them and its members to advise them on a whole gamut of issues in general practice.
“The IMO have recently concluded negotiations which brings an end to FEMPI. We have negotiated significant remuneration for the delivery of chronic disease management in primary care. I think that is hugely significant and sets a precedent.”
Dr McGarry added: “I am confident that GPs aren’t foolish. They will look at the choice available to them; they should decide who will represent them in a business-like way. It’s not a beauty contest.”
The viability of extending free GP care
Last month, some GPs reacted angrily online to reports that former Minister for Health James Reilly had outlined in party leaflets distributed in his north Dublin constituency that free GP care for children is to be extended to under-eights next summer.
“I think what GPs are finding difficult at the moment is the fact that negotiations for the extension of care to under-eights have not even started yet,” Dr Ó Tuathail told MI.
“Minister Reilly actually announced the dates; that process [of negotiations] has not started. I think it is really disrespectful to my IMO GP colleagues to make an announcement a fait accompli when the negotiations have not even started. It’s incredibly disrespectful to my GP colleagues in the IMO who work really hard.
“I think Minister [for Health Simon] Harris has been more cautious. What he has said was that it is his intention to bring an extension [to under-eights].”
In terms of upcoming talks between the IMO and Government on the extension of free GP care, IMO President Dr McGarry told MI: “We actually haven’t got a date for them, and that is being honest.”
“I note that there were a number of comments made by various members of the Government as to the roll-out in the beginning of the new year. [But] we have not had a sit-down meeting, or a date yet for a sit-down meeting. I expect that will be coming relatively soon. But I do not have that date yet.”
Mr McGarry said it was important that the IMO has input into the roll-out.
“The Government have their policy,” said Dr McGarry. “They can give out medical cards to whichever cohort they wish to. They could actually introduce it without any negotiation, should they wish to do it. But we felt it would be better if they were going to do it… that we would enter into negotiations with them, rather than have it just as a sort of enforced situation.
“So we are ready to enter into negotiations on that, the outcome of which is yet to be determined. I suppose that is what negotiations are. There will be toing and froing and hopefully [we] come to some sort of accommodation at the end of the day.”
Dr McGarry outlined that the IMO agreement with the Government is a “three-legged agreement, where each individual member can take or not take part. They don’t have to sign up to it, or any of it at all.”
According to latest figures, Dr McGarry said 97 per cent of GPs in practice with GMS lists have signed-up to the productivity measures in relation to FEMPI reversal. He added that the FEMPI reversal started taking place in July.
GPs will be sent information regarding the chronic disease aspect of the deal later this year.
However, some doctors are concerned with the extension of free care to under-eights and beyond.
“We are having difficulties in out-of-hours,” Dr Ó Tuathail told MI.
“At the moment in Dublin, in out-of-hours there are difficulties in getting the shifts covered. If you look at North-East Doc (North East Doctor On-Call (NEDOC)), it’s having increasing difficulties having GP cover and increasing difficulties with the red-eye shift.
“If you look at Cork, with Southdoc, what we are seeing is, it’s really coming to the fore this summer and coming into the winter.
“What we are seeing is out-of-hours being under huge pressure at a time of the year that would classically be quiet. We are moving into the period which is the busiest, which is the winter period, and already our out-of-hours services are under huge pressure, and that includes Dublin.”
Dr Ó Tuathail noted that a large number of child patients are presenting in out-of-hours, thus further extension of free GP care would increase this workload.
“There has been a sea change in out-of-hours services since the introduction of [free care for] under-sixes. When I would do an out-of-hours shift, at least 50 per cent of those who I am seeing are children under six. In some cases, more.
“What we are going to see with the introduction of the [free care for] under-eights, under-10s, under 12s, is a huge increase in presentation and more pressure on the out-of-hours [services].”
Dr Ó Tuathail believes negotiations and discussions with Government should focus on out-of-hours.
“Out-of-hours has not been an item for discussion; I think it should be. That is where the pressure is,” he said.
“It will naturally become part of the agenda because it is the natural pressure point in general practice. What we should be doing is coming up with some plan and solution to address the issue of out-of-hours and that is the conversation we should be having, and the conversation that the Minister should be having with GPs. Instead, the conversation is around how we increase access to GPs,” he said.
“We have really finite resources; out-of-hours is stretched to capacity. What the Minister has said now is, he is going to increase the access to that really finite resource further.”
On the deal struck between the IMO and the Government earlier this year, Dr Harty sees positives and negatives in the agreement.
“Part one of the three-part agreement has brought a stability fund to return some of the funding that had been removed from general practice by FEMPI since 2010 and this has allowed some practices to become financially viable and stable,” Dr Harty told MI.
“I think that was very important. The funding issue was driving people out of general practice. So I think that was a very positive move and I do think it has helped practices stabilise and existing practices to continue to function.”
However, Dr Harty said he was worried that the deal was not enough to encourage young doctors into general practice.
“Well, I was personally disappointed that there were no parallel negotiations [between the IMO and Government] in relation to the development of a new contract,” said Dr Harty.
“It looks like there will not be serious negotiations in building a new contract for at least four years, until this three-strand agreement works its way through the system, which I think is in 2022. That leaves a gap of three or four years where the existing contract continues, which is fairly unattractive for young GPs to take up. We are going to have a huge manpower crisis.”