All at sea: rural doctors in crisis
First it was the village post office, then the garda station. Now it's the turn of the local GP to feel the squeeze.
Anyone who has sat by the bedside of a loved one and seen them slowly slip away will appreciate the importance of good end-of-life care. But trying to ensure patients have a good death is becoming increasingly difficult and it's what motivated one of Dr Liam Glynn's patients to get involved in the No Doctor, No Village campaign. The elderly gentleman spoke up at one of the organisation's recent meetings.
"I got involved because I want to die in my own bed," he said. "You are the only people who will give me that chance. I know that you would respect my final good wish."
No Doctor, No Village is a campaign that emerged last year because of problems in rural general practice. GPs are under more pressure than ever to work evenings and weekends, to see more patients and to run their practices with less money. They are feeling unloved, overstretched, got at: caught between the ever-increasing demands of patients and what they believe to be unreasonable cuts from government for rural practices. All the negative publicity is having an effect: complaints about GPs are rising and their stock has never been lower.
The HSE denies that the numbers of GPs in Ireland are falling. A spokesman said the HSE had 2,000 contracts with GPs in 2009 and in 2015 that had risen to 2,400. As of January 1, there were 15 general medical services (GMS) GP lists out of a national total of more than 2,400 without a permanent GP in place. Five of the 15 GP vacancies were in rural areas. But results from an Irish College of General Practitioners survey last year revealed that around one in five GPs are aged 60 or over, with almost one in three aged over 55. Some regions are more affected than others. For example, over a third of GPs in Carlow are aged over 60. In Clare, Cork, Laois and Wexford, at least 28pc are aged over 60.
Dr Liam Glynn became involved in the No Doctor, No Village campaign because he felt that the issue is also about the wider neglect of rural Ireland. "What's going on here is death by a thousand cuts. There are wider issues here than just GP services. It's about the isolated, elderly people living here. They've lost their public transport, they've lost their post office, they've lost their local garda station and now they're afraid they'll lose access to a doctor."
Dr Glynn practices in seaside Ballyvaughan. "It's a small rural practice of around 800 GMS patients," he explains. "We have plenty of young families on our books, although obviously it would be the elderly people who come in to see us most. This is what angers me. These are the people involved in building our state back in 1916 and now we've rendered them nameless and voiceless."
Underlying everything, of course, is the fact that increasing life expectancy means practices are having to deal with more and more elderly patients. Hospitals are full of old people who need care rather than treatment, and the shortage of beds means other patients are being discharged earlier, putting more stress on surgeries. Community general practice receives less than 2.5pc of the overall health budget despite having over 90pc of the patient contacts. The savage cuts made during austerity are what Dr Glynn attributes the decline in the country doctor to. The questions are political, philosophical even. How much money are we willing to spend? Doctors currently receive €9 a month for each medical card patient. Some patients might have a few appointments a month so a busy practice does not necessarily mean a viable one. It means that low-attending patients subsidise elderly, chronically sick ones.
Now Kilmihill-based GP Dr Michael Harty is running for election, campaigning for a "rural revolution". Mayo GP Dr Jerry Cowley will also run. Harty has run his single-handed practice for 32 years and while he has voted in every election, he wasn't political until now.
"We've had meetings with politicians and while there was a general understanding between us all, there was no guarantee that anything would happen. So, if we can't achieve our goals through the normal channels, we'll have to do it through the ballot box."
Dr Harty says that rural practices are not sustainable without restoration of some of the cuts made to GPs' pay and conditions under FEMPI (Financial Emergency Measures in the Public Interest) or the Rural Practice Allowance, or both. "The Rural Practice Allowance is a specific payment awarded under the General Medical Card Scheme to GPs who practice in a village with a population of less than 500, and who are more than three miles away from a town with a population of 1,500 or more. It was worth around €16,000 a year to doctors before it was removed.
"When the local doctor in Bansha, Co Tipperary retired, his position was initially advertised without the Rural Practice Allowance. There were no applications. Eventually it was advertised with half of the allowance but still there weren't any applicants."
Pity the poor young doctors setting out on their careers. Medical students no longer see being a GP as the attractive, life-defining career it once was.
The hours can be difficult, the workload heavy. Many prefer to emigrate to Australia and New Zealand, where life is easier, pay is far higher and their careers far less rigidly structured. Research carried out by the Irish College of General Pracitioners shows that 12.5pc of trainee GPs are planning on emigrating post-qualification and a further 25pc are undecided.
Despite everything, it's still a vocation and a lifestyle that Dr Glynn doesn't regret. "Working as a rural GP is an enormous privilege, the most satisfying job anybody could do. You get to know people and their entire families over the generations. You get to know the new babies being born in the town. There's a quality attached to rural life, but it's only viable if people have the services the need. It's a case of the chicken and the egg."
Negotiations on a new GP contract between the Department of Health, the HSE and the IMO are continuing. Back on the campaign trail, Dr Harty is espousing an Obamaism: "Change will not come if we wait for some other person or if we wait for some other time. This really sums up what we're at.
''We have to do it now because it will be too late in five years' time."