Dr Brendan O'Shea: 'How can we cure the growing problem of patient refusal?'
We need to retain our newly qualified GPs, and there are ways that it can be done, writes Dr Brendan O'Shea
Are you among The Refused, a private patient who cannot find a practice to register with? There are many such individuals in villages and towns nationwide.
It is a concern that nearly half of general practices are closed to people seeking to register and this impacts those who have a doctor as well as The Refused.
There are three GPs at our own practice in Co Kildare and we have had to again close our doors to new patients for safety and workload concerns. Working days are book-ended by earlier starts at 8am and struggling to get out by 7pm. Lunch is a sandwich over paperwork and an incessant mix of stressed busy clinics, phone calls and frequently futile administration.
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Primary Care Reimbursement Service (PCRS) administration is over-represented in this, with endless repetitious letters and forms validating the individual's medical needs. When a patient visits a GP using a medical card, it is the PCRS which pays the GP for most services, and payments are largely capped irrespective of the number of consultations.
Medical card holders can't easily be among The Refused, since the PCRS has the right to assign medical card patients to the lists of GPs who have otherwise closed their practice. This is frequently exercised. It is a paradoxical and almost unique instance in our healthcare system, where the public patient is actually and systematically advantaged over the private patient. This privilege is of course illusory. The GP has the right to take such individuals off their list after six months, which many do, adding to patient churn.
This all adds to the stress on GPs in clearly overburdened practices, particularly in remote rural and inner-city deprived practices, and has helped create the underclass of refused patients who, by default, increasingly rely on out-of-hours GP co-ops, themselves staffed by tired, overworked GPs.
In Co Kildare, where we have a busy, well-organised GP co-op for out-of-hours services, you can usually add on two or three additional sessions per month that bring the working day to 11pm or into the weekends.
Co-op sessions have higher proportions of serious acute consulting, with unfamiliar patients. During the last decade, increasing numbers we see on co-op duty are those who have recently moved into Co Kildare but are unable to find a local practice. Many include young families with higher medical need. This trend was markedly accentuated with increased paediatric consulting when the under-six medical card was introduced. Many mistakenly believe it is OK to use the co-op as a GP service, but it isn't.
Evidence clearly indicates the value of continuity and managed care for chronic conditions. The co-op is not designed for these. So, as the influx of people to the satellite counties continues, the pool of available GPs is static. Some of this is because young GPs leave after training. We have serious difficulty attracting younger colleagues. Co Kildare has 44 GPs per 100,000 population. It is 68 for Ireland and ranges between 90 and 110 for the NHS and Commonwealth health systems.
I was directly involved in postgraduate GP training between 2003 and 2015. Younger colleagues expressed serious difficulty with the unremitting grind of daily practice. They spoke of their trainers as exhausted and chronically stressed. As well-trained GPs, young GPs are not work-shy, but exceptionally resilient individuals. Many see how poor public hospital services for their public patients are. They find gross discrepancies in hospital care between public and private patients repugnant. They do not see themselves lining up for a life of shoring up this. GPs understand our incomes are reasonable, but staggering volumes of work, chronic uncertainty regarding hospital care and a seemingly impervious and, at times, hostile system of outdated management, particularly in public administration, are factors in their decisions to leave.
There are practical solutions which can be implemented. It takes more than nine years to train a GP. When the public hospital gulags are sorted out - and they must be -that will help retain GPs. On completing training, very well qualified and mobile young GPs enter a highly competitive global jobs market. They are snapped up. They are not naturally greedy individuals, but income and workload here must be competitive with the UK, Canada and Australia to stem the loss of new GPs.
Our system is understrength in GPs, but seriously understrength in practice nurses. Increasing volumes of selected work in general practice can be better done by practice nurses. This would be a less expensive and quicker part of the solution.
There is overwhelming international evidence that the best health outcomes happen in societies with strong primary care, freely available, delivered by adequate numbers of GPs and practice nurses. The NHS is an excellent example of value for money, equality and better health outcomes.
If Government wishes to extend free GP care to under-12s, which many regard as desirable, it is important to ensure adequate funding, so practices can recruit and accommodate more GPs and nurses. If not funded, weaker practices will close, and stronger practices may increase fees to a shrinking pool of private patients in order to survive.
The present limited extent to which this important Sunday Independent survey indicates GPs are 'vetting' patients is encouraging, but more workload is likely to see more practices turning away people with more complex health needs, which would be deeply regrettable. The volume of The Refused will, thus, grow.
People unable to find a practice need to clearly tell their public representatives. If you are among The Refused, you might also ascertain their knowledge regarding Slaintecare - plans to reform healthcare into a single-tier system in which patients are treated on the basis of need rather than ability to pay. Ask your public representative what is their commitment to it.
Access to primary care is regarded as a right throughout Europe, but not here. If you are among The Refused, your local political representatives need to know of your existence.
Dr Brendan O' Shea is a GP and principal in practice in Co Kildare, on council at the Irish College of General Practitioners, and adjunct assistant professor at Trinity College Dublin
We make 350 phone calls to get national picture on healthcare
The Sunday Independent made more than 350 phone calls to GP practices over the past month to shed light on the availability of doctors in every community across the country. Our aim was to demonstrate what issues patients encounter when trying to access medical care.
Each practice was asked: “Are you taking on new patients?” In some cases we were met with a straight response. When we were told “no” there would often be an apology.
Sometimes, another practice would be suggested by the person answering the call. When we heard “yes” this would be followed by some chat about opening hours and how to register before our reporter resisted disclosing personal details and politely brought the conversation to an end.
In other instances the practice sought personal details. “Is it for yourself? Who am I speaking to? Where are you living? Are you a private patient or medical card holder?”
To deal with such questions it was necessary to exchange information.
Our undercover journalist posed as somebody who was new to the area. He was a prospective private patient looking to register with a local GP practice.
This element of subterfuge was justified as the only accurate way of verifying the response a member of the public would receive. The investigation was carried out in a manner similar to a secret-shopper survey.
Not every call to a practice was successful. In some cases the doctor was away, out on call or nobody was available. However, on 336 occasions a Sunday Independent journalist spoke to somebody and posed the question.