GPs battle to survive bloated bureaucracy syndrome
The prognosis for health service reform is grim as long as local doctors are angry and in despair, writes Eddie Hobbs
The long-term damage caused to Irish society from the choices made in the division of scarce resources continues to unfold and with it the chilling conclusion that the most powerful prevailed. Not included as insiders, yet occupying treacherous territory between the most powerful self-preserving State bureaucracy and their patients, lie Ireland's 2,800 General Practitioners.
Wednesday night, April 9, huge numbers of GPs turned out in Dublin to discuss their plight and that of the patients they've sworn to serve. Sadly none of the members of the Dail who addressed the meeting had really listened, failing to grasp the analysis, especially that of Dr Ed Walsh, but skilled enough to appear empathetic while concealing a hopeless ineptitude at addressing the core problem.
The outcome of protecting insiders has meant that 70 per cent of the Government's largest spend has been horded within the castle keep, sanctified by formal deals, Croke Park and Haddington Road and anointed in the outdated language of socialism.
Little of the vast spend on the health budget by the State's largest employer, gets to GPs who are on starvation rations on low single digits, compared to vastly greater allocations to GPs in better functioning health services. Financial resource triage, applied through the Financial Emergency Measures in the Public Interest Act (FEMPI), has contributed to GPs' gross revenues being emasculated, dropping nearly 40 per cent.
The results are deeply worrying in a sector already operating at 60 per cent of the density of GPs in Germany. Young doctors are emigrating, older doctors are retiring, practices are closing and the squeezed middle, trapped by mortgage debts are terrified by what appears to be a crisis, now out of control in the arm of the health services that deals with well over 90 per cent of medical needs, without referral to hospitals.
Upon this sand, the Government plans to build its primary care strategy, introduce free GP services to under-sixes by squeezing resources even further while shunting towards a vague destination with universal health insurance. Based on speakers at the gathering, the Government can build nothing on the magma of distrust, anger and despair seeping from GPs.
Dr Ed Walsh, who spoke at the event, calculates that at least €1.5bn and perhaps up to €3bn in the €13bn spend on health is due to inefficiencies caused by an outsized bureaucracy devoid of technology that links it all together. On an age-adjusted basis and despite cuts in the health budget, Ireland has among the highest OECD spends.
At the heart of the behemoth there are 15,000 managers, 9,000 general support staff and 17,000 'others' and not enough GPs or hospital consultants. No matter how you slice and dice it, every time resources are diverted to support the insider agreements, someone else pays and there can be no modernisation of the health service so long as successive political establishments continue to tip-toe around the clash between reform and insider power.
If GPs as SMEs are under threat, then so too are their 1.6 million medical card (GMS) patients, meanwhile many who do not qualify for State aid are rationing doctor visits.
To add further to the complicated and hostile atmosphere, the HSE has been ducking behind the deregulation of GPs under the Health Act 2012 to disengage from negotiation while doctors themselves, distracted by the Irish Medical Organisation (IMO), have failed to grasp that there are grounds to deal with the HSE without falling foul of competition law. For the time being the solution is being blurred by legal gun smoke.
On May 21, a civil trial begins at the High Court between the Competition Authority and the IMO. On the line isn't just a legal bill estimated at €1m-plus, but also perhaps the continued existence of the IMO whose core offering as a price-maker is at risk of ending at a time when GPs feel let down by the governance fiasco that failed to diagnose the vast pension liability of its former CEO – despite clear accounting rules to the contrary.
A 2009 study by the Competition Authority identified a range of restrictive practices surrounding the awarding and management of GMS contracts and in advertising but its most startling finding was the breach of Section 4 of The Competition Act 1991 which outlaws cartels, a finding that identified GPs as 'undertakings' of self-employed practitioners engaged in horizontal agreements as between one another, that had, as their objective, the prevention, restriction or distortion of competition. In doing so the Competition Authority fingered the agreement between the Minister for Health and the IMO as a price negotiator, as offensive to Irish and EU Competition law.
When the IMO, who'd already been the subject of an April 2005 raid by the Competition Authority over price fixing insurance medicals and who'd agreed to discontinue the practice in a 2007 settlement, decided six years later, on July 8, 2013, to withdraw certain medical services, the Competition Authority, struck again, this time dragging the IMO into the High Court.
The IMO has counter- claimed that GPs are not self-employed 'undertakings' but rather are employees of the HSE, thus repositioning the IMO as a trade union negotiating employment contracts and not a collective, fixing prices for service agreements.
Last week I told the GP audience to be wary of being recast as employees and to expect the battle to go all the way to The Supreme Court – and for the IMO to lose. The real issue isn't the long outstanding deregulation of the GP market but rather the hegemony of the HSE and its failure to adequately engage.
It is perfectly possible to arrive at fair fees through arbitrators but what cannot work is expansion by decree, ducking behind competition rules while funnelling scarce resources away from the frontline into a vast number of 'safe' jobs that were already well past their sell-by date when the health boards gave birth to the HSE 10 years ago.