menu ☰
menu ˟

Nothing attractive about 50-hour a week ‘part-time’ general practice

25 May 2017

Dear Editor,
With your permission, I would prefer for you not to release my real name for reasons that will shortly become apparent. And the name that is used herein is fictitious.

I read in the IMT of April 28, 2017 that the number of training places for GPs has increased by 65 per cent to 186 places today and that it will increase in the future to 240 places (‘Deal agreed to transfer GP training’). However, the same article states that in certain training schemes a number of places remain unfilled.

The unattractiveness of the GP profession and the lure of overseas work in preference to remaining in Ireland subsequently therefore begs the question ‘why?’ The reason would appear to be that the GP profession in Ireland is no longer an attractive one.

My GP wife Aoife established her own practice nine years ago. Prior to setting up, both she and a female colleague applied for or enquired about jointly taking on several GMS lists, all without any success. Eventually her colleague emigrated, and remains overseas.

At this time it was also almost impossible to get a job working for another GP with a view to partnership within a defined timeline. It may be recalled that such was the frustration then that ‘young’ (including GPs in their 40s) doctors formed the ‘Network of Establishing GPs’. Given all of the obstacles Aoife faced she eventually felt forced to take the risk of setting up her own medical practice.

By risk I mean both the risk of failure, and the risk of illness.

While anybody setting up a new business will face the risk of failure, the reality for any GP commencing a business is that they can cover the risk of death by paying for life assurance, but if they get sick they will not be covered by Permanent Health Insurance, which many employees take for granted, because when they start out they do not have an insurable income (until such time as they are making enough money that can be insured).

There is also a significant chance that serious illness cover will not cover many such illnesses because this is restricted to very serious illnesses, many of which result in death in the near term, and exclude more mundane illnesses that may be energy sapping, such that a person cannot work, but which are not likely to be fatal. So Aoife carried, and carries, a very significant risk which is related to her health.

At that time established GPs had a stranglehold over the profession. This meant that many young and not so young GPs were prohibited/ blocked from taking on GMS lists, Aoife included, and all of this with the blessing of established GPs. However, within two years of setting up she did secure her own GMS number and was then able to start building up her own GMS list.

Aoife now works ‘part-time’, and over the years the practice has been built up to include another part-time GP, a part-time nurse and two part-time secretaries, as well as locum doctors when they can be found.

She currently pays wages of €150,000. Including our child minder, she is responsible for the livelihoods of five people, plus whatever is paid to locum doctors.

Unfortunately the GMS side of the practice was developed just as GMS fees were cut by 38 per cent, and this has had a hugely negative impact on the financial performance of the practice.

Aoife has never earned more than her assistant GP over the years, and never a six-figure sum. In fact, she is in the position that had I, her spouse, not been earning over the years, she would not have been able to meet the repayments on her loans and would have gone into default with her bank, as have other GPs in well publicised cases.

By not being able to meet the repayments on her loans, I mean that after one has deducted tax from her gross income that her after-tax income does not or barely covers her loan payments, the cost of the building not being allowed against tax.

Given this difficult situation she seriously considered giving up her GMS list and adjusting her overheads such that she would earn the same income from private patients, only with a significantly reduced administrative burden, and perhaps do some locum work for other doctors to earn more money, but that step has not been taken.

As a doctor she prefers a mix of private and GMS patients, which she says makes medicine more satisfying. We have three young children and Aoife now works ‘part-time’. By that I mean ‘part time’ for a doctor. Part-time means that she works all day Monday until 7.30pm, all day Tuesday until 5pm, on Wednesday until about 2.30pm and on Thursday until about 4pm. She does not take lunch breaks. She does some paperwork on Friday for a couple of hours and will also do paperwork on several evenings on the kitchen table, will often drop into the practice for two-to-three hours on a Saturday and very occasionally on a Sunday.

Working on the kitchen table from 8pm on a Sunday evening is a common occurrence.

She will also attend GP CPD evenings about three times every two months and will spend about one full Saturday every quarter on a medical course.

She has also had to double her out-of-hours commitment due to the impact of the under-sixes demand and the unavailability of locum doctors. This commitment is now seven hours, including travel every three weeks, in either the evening or at the weekend. Apparently this is quite good compared to what doctors in other areas of the country must work.

We estimate that her average weekly time commitment is just under 50 hours, even though she only works ‘part-time’. She has great sympathy for doctors who work ‘full time’.

Recently, in order to develop her practice in which she has invested so much, both financially and in terms of time and effort, Aoife decided to apply to take on a trainee GP. She is a clinical GP tutor and over the years has taken medical students into her practice on a regular basis.

However, because she has just under 900 GMS patients she has recently been informed that she does not qualify to be considered for interview to take on a GP trainee as she does not meet the shortlisting criteria of a list of 1,000 GMS patients. This has been increased from a previously lower figure when she applied previously.

Aoife is therefore now in the position of having a well established practice, in a purpose-built and modern premises, with a loan she still can barely afford to repay, but she is not entitled to take on a trainee GP, which is the next step she had always planned for her practice. Her practice is operating to capacity and on many days has to turn away patients. A trainee GP would appear to be the perfect fit both for her and for the training authorities who insist that trainee GPs must be able to work in practices that give a broad and representative breadth of work experience.

Her GP trainee would also experience working in a purpose-built GMS practice, which is not an opportunity that I expect all GP trainers would be able to offer.

Given the facts that I set out above, is it any wonder that individuals with a sincere interest in being GPs train to be GPs but then leave Ireland to work elsewhere?

I cannot imagine any potential GP who has read this far taking any motivation whatsoever to work as a GP in Ireland.

In the past, I suggested to Aoife that we sell up and leave Ireland, given the very poor quality of life she in particular endures.

She said she prefers Ireland. Last year, she casually said that her dream was to win the Lotto, to repay her loan and to give up her practice. She said she would prefer to do locum work for set hours.

And the final indignity that she suffers every now and again is meeting with a former class-mate who is now a hospital consultant and who sincerely commiserates with her lot as a GP.

I have observed the HSE, the IMO and the ICGP over the years. I have also observed the then established GPs who had the opportunity for decades to be generous to newly establishing GPs and who happily (all the way to the bank) refused to be so by making it very difficult for non-established doctors to take on their own GMS lists and therefore establish.

It would appear to me that they all require a very significant infusion of the ‘common sense’ that Dr Tom O’Rourke recommended for the Irish Medical Council recently (‘Closing of list is not a matter for IMC’, IMT, April 28, 2017), when he highlighted it was receiving and investigating complaints about GPs who are currently operating to capacity and who are being forced to refuse new patients, who then complain them to the IMC for refusing to take them on. I would add kindness to this infusion that Dr O’Rourke recommends in many cases also.

It appears to me that the first step required for general practice is to make the profession significantly more financially attractive and viable for new entrants (and by default existing GPs), which in turn should begin to ease the burden on existing GPs with a knock-on effect on working conditions generally, and furthermore encourage at least some of the emigrating GPs to remain in Ireland given the more attractive financial circumstances.

And it has to be sufficiently viable for GPs to be able to invest in setting up modern practices, and not just to earn a living. As I have already highlighted, almost all of Aoife’s income goes towards paying off a loan.

Lastly, all recent governments and politicians should be ashamed at how they are actively overseeing the destruction of what is potentially the most efficiently operating aspect of the Irish health system for political gain, that being general practice.

Political expediency and populism needs to be replaced by realistic, detailed, sensible and honourable planning that may in time enable the introduction of what politicians seem to want to be introduced, or are afraid to say they are not in favour of, which is free healthcare for all. But not for 30 years at least, please.

In conclusion, general practice is currently a basket case. There are many who should hang their heads in shame.

Name and address with Editor.

The post Nothing attractive about 50-hour a week ‘part-time’ general practice appeared first on Irish Medical Times.

Click here to view the full article which appeared in Irish Medical Times: Opinion

IPH Logo