Submission by the Rural, Island & Dispensing Doctors of Ireland
(Incorporated as the Institute of Rural Health CLG RCN :257949 on 07/12/1996).
INTRODUCTION
The health service is under serious pressure. Our government struggles to cope with massive escalation of costs. 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’, overwhelmed 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 compared to places such as Australia.
Ireland has been well served by their 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 IMO and 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.
What has brought about this change where no young GP can see a future for themselves in Irish rural practice? What are the blockages to GP’s starting practice/ remaining in rural practice?
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
That seems not so long ago, in a time before the dreaded FEMPI cuts. It is recognised that FEMPI inordinately affected rural practice. These FEMPI cuts removed 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 to be looked after.
(1) Financial insecurity due to FEMPI cuts. These cuts were reversed by government to a major degree over time, but not equitably. (1) They were part of wider Financial Emergency Measures in the Public Interest (FEMPI) cuts to public sector pay which have been largely reversed.
Irish pharmacists (2) as well as rural doctors (2) as well as the Bar Council (3) are similarly affected by the inequitable unwinding of FEMPI and are demanding that these cuts be fully reversed.
The Bar Council is seeking the full reversal of the 2008 cuts to the legal aid fees paid to its members who act in criminalcases. Barristers – represented by the Bar Council of Ireland – are looking to have fees fully restored to pre-FEMPI levels along with the restoration of the previous link to public sector pay rates. They also want an “independent, meaningful, time-limited and binding mechanism” established to set fees in the future (3)
The Bar Council are already engaged in a campaign of action to secure FEMPI cut reversal for their members.
Irish rural practice was disproportionately affected by FEMPI. In particular Irish rural GP practice was and still is in many respects the collateral damage from the FEMPI cuts.
See Solution 1. below.
(2) Inability to secure adequate time off due to a lack of locums. Inability even to take statutory leave.
Our problems on the ground continue unabated in rural single-handed practice. 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 CDM Programme, which can provide a badly-needed resource boost for GP’s, 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 particular situation. It failed due to an inability of the practice to guarantee the funds needed to pay for the extra associate doctor. This unfortunately has been my own personal experience of trying to recruit an associate under that scheme. I am aware of other rural GP colleagues in a similar position who struggled to remain in practice and who have similarly failed to get this much lauded scheme to help their situation and have subsequently resigned their GMS contract prematurely. The tragedy is thatt here is plenty of work to be done in rural practice, with patients arriving by the day from war torn areas of the world to every corner of rural Ireland (we have had 150 refugees from the Ukraine alone arrive here in Mulranny). Our practice population like every other scenic area invariably swells over the summer months with an influx of visitors. Frequent requests arrive here from other practice areas including the larger urban centres where some patients struggle to join and ultimately fail to get signed on to any GP practice. 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; a ‘fig leaf’ rolled out to cover the void in the rural medical service, where early retirement or resignation is the safety-valve to sanity for
those who remain.
It is cruel that those caring rural GP’s 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, and unless urgent action is taken, there will be no one left. There are solutions which need to be put in place to ensure areas continue to have a proper standard of GP service which is fit for purpose and accessible to those who need it. Anything less than a GP service is not the type of rural practice that will fit the bill for people needing the continuation of a local GP service which they have had for generations. Dr Mireille Sweeney who resigned recently after 29 years in Ardara Donegal as a GP was quoted in
the Irish Independent as saying that in the past two years at Ardara Health Centre, the post of
GP assistant, GP partner “and my post as principal GP have been offered to 11 doctors, nationally
and internationally. [They all showed] genuine interest in the practice but [were] unwilling to accept
the demands of a single-handed Rural GP practice.” (4)
See Solution 2 below.
Continuing loss of older people from their local area. The sad silent migration of older people to faraway institutions. No proper support for our older people to stay and be looked after by their GP/ own Community. 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 recognized as such and piloted.
This is very worthwhile work in my opinion and of massive humanitarian benefit to our older population, helping take the pressure off local A & E and out-of-hours services. This work needs to be better supported in view of the already greatly increased Irish population numbers in recent years, and especially those of 85 years and older. This age group already account for half of people in long stay care, and are projected to rise from 89,000 to a massive 222,000 over the next 20 years. (5)
See Solution No 3. below.
THE SOLUTIONS – PROPOSED BY Rural Island & Dispensing Doctors of Ireland (RIDDI)
(1) SOLUTION No 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) Solution No 2 – the ‘RIDDI 2 for 1’
There is an alternative solution – the ‘RIDDI 2 for 1’ – The Rural, Island & Dispensing Doctors of Ireland (RIDDI) proposes that these single-handed practices struggling with the recruitment and retention of rural practitioners, 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 2 doctor practices – the so called ‘RIDDI 2 for 1’.
This is now IMO policy after being passed at the IMO AGM 2023. (6)
‘The RIDDI 2 for 1’ will definitely cost more than just supporting one permanent single-handed rural doctor, but the extra cost of a second doctor can be easily rationalized by the fact that a single HSE temporary Locum is costing multiples of what it is now costing to support the original GP as reported recently in the Mayo News. (7)
If GPs looking for permanent posts can be assured of having their anticipated / expected time off 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 economic post- FEMPI era. We depend mainly on the GMS and we lack capacity to deal with the extra work from the GMS, including the influx of war zone refugees, all of which is still proving to be the final straw to break the back of the willing horse which is the rural GP. Having worked during my 48- year career as a one-in-one hospital intern as well as ‘one-in-one’ rural single-handed GP, I can assure you that a well- rested doctor is a safer and happier doctor. We contrast the alarming decline in the numbers of rural single-handed rural practitioners with the reciprocal ever-increasing dependence on hospital EDs, and an already overwhelmed out-of-hours service.
(3) SOLUTION NO 3 – 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 recognized as such and piloted. The WHO – UN Decade of Health Ageing (2021 -2030) (8) – challenges communities to deliver person-centred integrated care and primary health services responsive to older people, and provide older people who need it with access to quality long-term care. The biggest drawback of the trend towards bigger, privately -operated facilities is that the model does not work in rural settings. (9) Local people need more options and especially in the West of Ireland and particularly in rural counties such as Mayo and Leitrim where the percentage population of older people are highest, and where there are already insufficient long-term care beds available (10). 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 (11) 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 for each long term residential institution (12)
Valuable work is already being done in social enterprises run by communities such as the St Brendan’s community village, in Mulranny, Co Mayo which provides a continuum of support to older people on a ‘not- for- profit’ basis, for the community by the community, and extending from home supports to sheltered housing, to high support care including convalescent, respite and palliative care, and IV antibiotics, all within the local community, so allowing older people the opportunity to stay locally, rather than having to migrate to a faraway institution. (13) (14). We are the biggest local employer.
There is more than enough work for two doctors here in Mulranny, taking into account the work involved in supporting our St Brendan’s village high support unit. This involves anticipatory care as well as the prevention of unnecessary admissions. The proposed Rural Island & Dispensing Doctors of Ireland (RIDDI two-for-one) solution of two doctors being appointed to a previously existing single- handed practice struggling to survive, 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.(14, 15 (Appendix A) This community- based model would work equally well in an inner- city area. ALSO (4) We fully support IMO and ICGP policy that single- handed GPs with RPA (rural practice allowance) are guaranteed 5 weeks protected annual leave, by locums provided by the HSE. We are glad that the 2023 Agreement reached between the IMO / 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. (16)
ALSO (5) We fully support IMO and the ICGP policy that all GP’s have access to out- of- hours services and that every GP has access to a locum. We fully support IMO policy that the HSE increase rural practice supports in respect of DMO salaries, Dispensing fees and the Rural Practice Allowance (RPA). The available locum subsidy is grossly inadequate and needs to reflect actual locum costs. Financial help with practice set-up costs is required also. Dispensing of medicines by some rural practitioners is an important and essential function provided to vulnerable populations. Rural practice supports in respect of Dispensing Fees, DMO salaries and the Rural Practice Allowance (RPA) help sustain the following: 12 DMOs -unchanged in 16 years since Benchmarking. 30 Dispensing GPs- fees increased by 27% over 3 years in 2019 deal. 256 RPA -increased by 37% from €16K in 2016 to current €22k. All have fallen significantly below capitation increases of 48% over 3 years in the 2019 deal and a further 10% capitation rise in 2023 deal. Many rural remote lists are smaller and depend on these extra incomes to remain attractive for recruitment and retention. Cost to 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 (17).
RIDDI as a stakeholder in rural Ireland will continue to work in equal partnership with the Irish College of General Practitioners (ICGP), the Irish Medical Organisation (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 OECD. The voices of rural communities must be heard and listened to in a spirit of partnership and equality. “Nothing about us without us.” (15) – see Appendix A
About RIDDI- (Incorporated as the Institute of Rural Health)
RIDDI (Rural Island & Dispensing Doctors of Ireland) was established in 1984 with the aim of sustaining an acceptable level of GP and associated medical services in rural Ireland. Our demand has been for government to sustain smaller towns and rural areas by providing adequate resources, and so prevent the vicious circle of loss of further services with continuing depopulation. We were glad on behalf of our rural colleagues to have been instrumental over the years in promoting the rural agenda through our 36 annual conferences held at different locations throughout the State, and happy with the support of our rural colleagues, through our representative and professional bodies, to have made some positive progress for better
medical services and conditions for rural doctors. These include pension entitlement changes, introducing the concept of co ops for a proper out-of-hours GP service, and championing the establishment of a dedicated helicopter emergency medical service (HEMS). RIDDI organised the WONCA World Rural Health Conference, in June 2022, in equal partnership with the Irish College of GPs, and UL School of Medicine.
Dr Jerry Cowley, MB BCH BAO D.Ch D.Obst MRCGP MICGP LLB BL DFP DM(HC) D.DM 29/08/2024 on behalf of Rural Island & Dispensing Doctors of Ireland (RIDDI)
References
Ref 1 ‘Two -for- one’ answer to rural practice crisis? Forum Vol 41 No 6 July/Aug 2024
Ref 2 Letters Irish Times: Ongoing impact of FEMPI measures: GP surgeries and pharmacies are still feeling the effects, Irish Times Jul 4 2024
Ref 3 Editorial Irish Times: The Irish Times view on the barrister’s strike: a case worth making. July 4th 2024.
Ref 4 Irish Independent 03/06/2024. “Heavy workload forces yet another rural GP to quit as manpower crisis worsens”
Ref 5 Health in Ireland Key Trends Report Eurostat 2022
Ref 6 IMO AGM 2024 Update on AGM Motions 2023. Rural General Practice ‘RIDDI 2 for 1’
Ref 7 Mayo News 28/02/2024 -” Achill GP post vacant since 2020 to be advertised yet again”
Ref 8 The WHO – UN Decade of Health Ageing (2021 -2030) – is aligned with the 2030 Agenda for Sustainable Development and a commitment by all Member States to improve the lives of current and future generations of older people. Developing age- friendly cities and communities is a proven way to create age-friendly environments
Ref 9 The Irish Times view on nursing home -ownership: “People need more options.” Editorial Jan 10 2024
Ref 10 Long –Term Residential Care in Ireland: Developments since the onset of the Covid-19 pandemic: ESRI No174 9th Jan 2024
Ref 11 A community-based model of care: Irish Times letter Feb 20 2024
Ref 12 https://sageadvocacy.ie/policy/ Choice Matters: Towards a Continuum of Support and Care for Older People – Sage Advocacy – A Discussion Document 2020
Ref 13 www.stbrendansvillage.com St Brendan’s Community Village Mulranny website:
Ref 14 https://www.independent.ie/regionals/mayo/news/community-care-facility-in-mayo-under-long-term-threat-due-to-lack-of-investment/a2133834517.html
Ref 15 / Appendix A Rural Island & Dispensing Doctors of Ireland (RIDDI) Statement at WONCA Rural World Conference (18/06/22) UL Limerick Ireland.
Ref 16 IMO AGM 2024 Update on AGM Motions 2023. P48 Rural General Practice
Ref 17 Flavin Aonghus, IMO AGM 6th April 2024
APPENDIX A
Appendix A (Ref 15) Rural Island & Dispensing Doctors of Ireland (RIDDI) Statement
(WONCA World Rural Health Conference 20/06/22)
Thirty-five annual conferences later and in the spirit of Alma Alta, the Rural Island and Dispensing Doctors of Ireland (RIDDI) assert the right of Irish rural dwellers to enjoy optimal physical and mental health, in addition to economic and social wellbeing. In this regard and recognising that Irish rural medical practitioners are an essential part of the extensive Irish rural infrastructure we call on government to guarantee that Irish rural practice is sustainable into the future by ensuring as a first step that sufficient medical practitioners are retained and supported in rural areas. By using novel schemes including succession plans, Government must ensure that all vacant and locum- run rural and remote area GP panels are filled as a matter of urgency.
Due to serious issues with the recruitment and retention of rural practitioners in the most isolated rural areas and on the offshore islands, we urge that these isolated solo practices should instead operate with a second GP appointed to them and be fully resourced by the HSE.
Imaginative GP Associate schemes are urgently required to address the looming workforce crisis due to the imminent retirement of hundreds of ageing rural medical practitioners. A “thinking outside the box” approach by Government to sustain smaller rural and semi- rural practices is overdue. Models looking at extra staff including shared practice managers, practice nurses and other practice support staff such as physician associates, student, and post graduate interns are options which require to be considered. To counteract the serious and growing problem of rural medical practitioner burnout, RIDDI suggests creating a resourced virtual campus.
We are committed to fully engaging with our patient advocacy groups in our quest for a better future for all rural dwellers. Improving local rural services as a powerful weapon for rural regeneration, to break the vicious circle of further rural depopulation, has been RIDDI’s catch-call for decades. Supporting older people locally, including in congregated settings when appropriate, is integral to the work and viability of rural medical practitioners. So is the dispensing of medicines in areas where it is not economically feasible for a pharmacist to operate. Both the aforementioned need to be fully supported and developed further for the sake of rural dwellers.
The recent COVID -19 experience has shown us the value of cooperation, including the sharing of expertise and financial resources between rural medical practitioners, long- stay care providers, the Health Service Executive (HSE), and Government, which has enabled local services to be supported and sustained throughout the pandemic
.
The return during COVID by many younger people to rural areas who can see the clear life- enriching advantages of lower cost living and working in rural Ireland has engendered new hope with greater potential for rural regeneration, but has resulted in an increased workload for already hard pressed rural medical practitioners. While reiterating that Irish rural medical practitioners are an essential part of the rural infrastructure, we call on our Government and the HSE to revisit and build on this newfound spirit of cooperation and support engendered during COVID and so ensure rural medical practitioners are facilitated to take due time off by providing a locum bureau, and ensure the viability of local congregated settings providers, whether they be HSE -funded or private, by ensuring they are adequately and equally resourced.
We will continue to forge links with third level institutions in a spirit of true equal partnership rather than on a “country cousins” approach, and in accordance with our constitution.
Young students in health sciences should all be given a chance to experience the amenity of rural communities and training in those communities.
We are certain that rural practitioners are willing and able to contribute further and significantly to the rural research base. We need meaningful and relevant evidence- based rural practice research with the agenda being set by local communities and their practitioners on the ground, which can advance our cause going forward on behalf of our rural population.
The rural medical practitioner is the first “port of call” in every rural “storm” with often no colleague or Emergency Department close to hand. The acute critical care role of remote rural medical practitioners needs to be recognised and supported adequately with essential training and equipment.
We call for the restoration of the distance codes system, the abolition of which has amounted to a massive disincentive to rural practice as a career choice for young medical practitioners. We are confident that adopting the aforementioned will not only stop the exodus of medical practitioners from rural Ireland, but will actually reverse it.
A Chair of Rural General Practice should be resourced within a higher education institution nationally.
Our partners in this conference the Irish College of General Practitioners (ICGP) already provide Clinical Leads for diabetes, global health, mental health etc. We would welcome an ICGP Clinical Lead in Rural Health, while acknowledging the major support offered already by the ICGP to Irish GPs through their extensive CME network in particular. We need to prioritise Vocational training and placement of GP Registrars in rural practice.
RIDDI as a stakeholder in rural Ireland will continue to work in equal partnership with the Irish College of General Practitioners (ICGP), the Irish Medical Organisation (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 OECD. The voices of rural communities must be heard and listened to in a spirit of partnership and equality. “Nothing about us without us.”
We demand that our Government Department of Rural and Community Development and the Health Service Executive partner with us in our quest for rural practice sustainability.
Ní neart go cur le chéile. There’s strength in unity.
To quote Fintan O’Toole at WONCA World Rural Health Conference Limerick 2022
“There is no clearer way of telling people they are unequal than denying them access to healthcare”
As Dr Anna Stavdal, President of WONCA, said today – ‘Family Doctors- Always There To Care’- but, in Rural Ireland- there is a real risk they may not be!
END