The health service is under serious pressure. Our government struggles to cope with a massive escalation of costs. And rural doctors are losing out financially and socially – as are their patients writes Dr Jerry Cowley
A visit to any local ED will disclose a multitude of doctors struggling to cope with the flow of patients, confirming to us that rural doctors are being replaced by a growing ED industry, over whelmed by the increased volume of work.
In the meantime, droves of young Irish-trained doctors head for greener pastures such as Australia post-qualification. They emigrate because they see no future in Irish general practice due to a lack of set-up cost supports and inferior working conditions.
Ireland has been well served by single-handed family doctors for generations. The continuity of care has been second-to-none, and its great benefit has been proven by hard research.
The Irish Medical Organisation (IMO) and Irish College of GPs (ICGP) have worked tirelessly to ensure proper working conditions and quality standards, not least for those of us based in the more isolated rural areas and on our offshore islands.
Yet everything has changed. Why has this happened?
1. Financial insecurity due to FEMPI cuts
Time was when a rural GP could be sure that on retirement, he or she would have a replacement doctor to take over the practice. This was before the dreaded the FEMPI (Financial Emergency Measures in the Public Interest) legislation.
These FEMPI cuts affected the future of Irish rural practice overnight by the removal of an inherently fair payment system based on demographics and distance, which favoured those practices which were most rural, and with greater numbers of older patients.
These cuts were reversed by government to a major degree over time, but not equitably. Irish rural practice was disproportionately affected by FEMPI. Irish rural GP practice was, and still is, in many respects, the collateral damage from the FEMPI cuts.
2. Inability to take time off – or even statutory leave – due to a lack of locums
The ‘elephant in the room’ is an inability to secure adequate time off due to a lack of locums, further compounding burnout, and recruitment and retention difficulties in rural practice.
The chronic disease management programme, which can provide a badly needed resource boost for GPs, cannot achieve the desired effect in rural practice due to time constraints.
In addition, hiring an assistant or appointing a partner can be a step too far for many.
Even the International Medical Graduates (Non-EU GP) Programme is proving to be a non-runner for the individual remote and isolated single-handed practices that I am aware of who tried to make this novel scheme fit their situation. It failed due to an inability of the practice to guarantee the funds needed to pay for the extra associate doctor.
Providing temporary locums is a sticking plaster solution put in place by the HSE to fill rural practices vacancies that no one else will fill permanently.
It is cruel that those caring rural GPs still remaining in rural practice continue to struggle to find cover to attend a family funeral, go on holidays, or even take sick leave or maternity leave.
So many caring and dedicated doctors have already left and more continue to resign. Unless urgent action is taken, there will be no one left.
3. The sad silent migration of older people to faraway institutions
The potential role of rural GPs helping support older people to stay locally, no matter what their condition, is a powerful humanitarian and economic resource and should be recognised as such and piloted.
This is very worthwhile work and of massive humanitarian benefit to our older population, helping take the pressure off local ED and out-of-hours services.
This work needs to be better supported as our population gets older. Over-85s already account for half o people in long-stay care, and are projected to rise from 89,000 to a massive 222,000 over the next 20 years.
So, what are the solutions? Here is what Rural Island and Dispensing Doctors of Ireland (RIDDI) proposes.
1. Reverse FEMPI cuts
It is recognised that FEMPI inordinately affected rural practice. These FEMPI cuts removed the future of Irish rural practice virtually overnight. Rural practice has
never recovered.
2. The ‘RIDDI 2 for 1’
RIDDI proposes that single-handed practices struggling with the recruitment and retention or rural practitioner in the more isolated rural areas and on the offshore islands should operate with a second GP appointed to them, fully resourced by the HSE, and become two-doc-tor practices – the so-called ‘RIDDI 2 for 1.
The extra cost or a second doctor can be easily rationalised by the fact that a single HSE temporary locum is costing multiples of what it is now costing to support the original GP.
If GPs looking for permanent posts can be assured of being able to take time on through having another GP in the practice, then they will come to rural areas.
Having a second GP would mean no more locum problems, and an extra pair of hands to deal with the increased volume endured by GPs in our struggling post-FEMPI era.
3. Recognise the role of rural GPs in helping older people to live locally
The World Health Organisation challenges communities to deliver person-centred integrated care and primary health services responsive to older people, and to provide access to quality long-term care.
However, bigger, privately-operated facilities do not work in rural settings. People need more options, especially in rural counties such as Mayo and Leitrim, where the percentage population of older people is highest, and where there are already insufficient long-term care beds available.
People should be given the choice to stay locally rather than having to travel – to live for the rest of their lives at a distant greenfield site where they know no-one.
As a core principle, nursing care units for people who require a high level of 24/7 care must be part of a community-based care support hub which includes a wide range of social care services and supported housing.
International research and the Covid-19 experience has underscored the value of a single GP practice to look after most or all residents with a dedicated medical officer (DMO) for each long-term residential institution.
Valuable work is already being done in social enterprises run by communities allowing older people the opportunity to stay locally.
The proposed RIDDI two-for-one solution would ensure a sustainable working model where our older folk have the guarantee to stay locally and be looked after, no matter what their disability. This community-based model would work equally well in an inner-city
area.
4. Protect annual leave
We fully support the IMO and ICGP policy that singlehanded GPs with a rural practice allowance (RPA) are guaranteed five weeks protected annual leave, by locums provided by the HSE. We are glad that the 2023 Agreement reached between the IMO and HSE provides additional funding for a pilot project to support the provision of GP services in isolated and rural areas and we look forward to more progress in that area.
5. Increase rural practice supports
We fully support IMO and ICGP policy that all GPs have access to out-of-hours services and that every GP has access to a locum.
We also support IMO policy that the HSE increase rural practice supports in respect of DMO salaries, dispensing fees and the RPA. The available locum subsidy is grossly inadequate, and needs to reflect actual locum costs. Financial help with practice set-up costs is also required.
Rural practice supports in respect of dispensing fees, DMO salaries and the RPA help sustain the following:
- 12 DMOs: unchanged in 16 years
- 30 Dispensing GPs: fees increased by 27 per cent over three years as part of a 2019 deal.
- 256 RPAs: this allowance has increased by 37 per cent from €16,000 in 2016 to €22,000 today.
All supports have fallen significantly below capitation increases of 48 per cent over three years in the 2019 deal and a further 10 per cent capitation rise in the 2023 deal.
Many rural remote lists are smaller and depend on these extra incomes to remain attractive for recruitment and retention. The cost to the exchequer of improving the financial situation for these allowances would be small due to our small numbers but would help boost recruitment and retention of those practices. RIDDI as a stakeholder in rural Ireland will continue to work in equal partnership with the ICGP, IMO, patient advocacy groups, and all other organisations which seek to improve the health of all rural dwellers, especially the most marginalised, including our ethnic travelling community and refugees.
We need to be mindful of our duty of care to our planet, and everything we do should be in an environmentally sustainable manner.
Above all we need to be central to the decision-making on the future of rural and semi-rural Irish general practice and have a meaningful representation at any table where decisions are being made which affect us; these need to be rural-proofed as agreed by the DECD.
The voices of rural communities must be heard and listened to in a spirit of partnership and equality.