Derek Harney

With great aplomb and to rapturous applause, from the party faithful at the PD annual get together, The Tanaiste and Minister for Health Mary Harney yesterday launched her latest initiative to tackle the nation’s healthcare crisis, although she didn’t actually use the word crisis, indeed she stressed that there was indeed no crisis in the delivery of health care in the country, merely as always is the case she added there is room for improvement. 

A beaming Tanaiste stated that her latest initiative would be a public private venture which with the stroke of a pen would solve any remaining health care delivery problems overnight, with no actual cost to the exchequer.  Indeed her proposals if properly and fully implemented she said would in fact leave the exchequer with a generous surplus, otherwise known as profit.

Outlining her plans Ms. Harney stated that she proposes to fastrack the building of a network of ultra-modern, fully automated, self-delivery health care centres, henceforth to be known as UMFASAS.  The building of these UMFASAS would be left to the private sector and naturally enough a generous tax break would be offered as an incentive. The Tanaiste however stressed that as she was ever mindful of the fact, that as tax breaks to date; in the area of building and development in particular, were seen by many as being as hogged by the few, the so called Golden Circle, which in reality didn’t exist, she was anxious at the outset here to stress that tax breaks for the UMFASAS would be available to all.   The Tanaiste said that she was more than aware that many would wish to invest their SSIAS in the UMFASAS, but alas for administrative and practical reasons however those wishing to participate in the scheme would have to commit resources or access leverage for a minimum of €2.5 million to participate in the scheme.  At first sight this might appear harsh to some, however the Tanaiste added that when one considers that many ordinary city folk fork routinely  fork out at least that sum million for  modest homes  a cut-off point of €2.5 million does not seem unreasonable.

Ms. Harney went on to say that hitherto her plans for reforming the nation’s healthcare delivery system had been hamstrung and hindered at every twist and turn by vested interests, in particular she singled out the nursing and medical professions for criticism.  The UMFASAS she stressed would not fall prey to these twin pillars of parasitism, for they would have no hand act or part in their operation.  The UMFASAS would be doctorless, nurseless and as far as possible para-medicalless.  The Tanaiste went on to give a brief outline of the mechanism of operation of the UMFASAS.  Every man woman and child in the country will be issued with a unique patient chip and pin card which they would key in at the point of entry.  An easy to follow symptom list will then appear on screen; everyone these days is computer friendly, and it is merely a simple matter for the patient to key in his or her complaints, the Tanaiste said. After a brief pause for analysis the software will then direct the patient to the next stage of the process. This might result in an advice being offered, a prescription being written or indeed the patient may be streamed for further investigations.  On site facilities will be available for X-Rays, CAT Scans, MRI Scans, ECG blood tests etc.  Arrangements have already been made to have the scans, ECGS and blood tests etc interpreted online in China, India and Sri Lanka at a fraction of the cost that it could be done for here.  There was one slight glitch however which to date has not quite been overcome and that is in the area of blood taking.  We did toy with the idea, the Tanaiste said of teaching patients to take their own blood, however on legal advice we have had to shelve this option, and on a holding basis only we have decided to put a limited number of phlebomists in place. These posts however will only be offered on a temporary basis until more sustainable arrangements can be made.   Whilst it is envisaged that the vast majority of units will be processed, treated and discharged as day cases,  more correctly hourly, half hourly or even in a  matter of minutes, nonetheless it is reasonable to assume that the more seriously ill or difficult cases will require overnight stay. To cater for this eventuality the UMFASAS will come complete with a limited number of beds.

It is not however thought that catering facilities as such will be required.  If the “full trolleys in casualty” scenario has thought us anything, the Tanaiste said it is that patients in hospital do not actually need full old syle hot meals. Tens of thousands of patients have done quite well in recent years for days on end on a diet of crisps, sandwiches and bottles of pop.  Learning from this situation we have decided to equip each UMFASA with a fine line of vending machines offering a broad range of all of the above. To satisfy the dietary needs of those patients confined to beds, or trolleys and unable to access the vending machines, the Tanaiste stated that her department had explored various options and after serious deliberations had decided to offer the franchise for same to Ryan Air.   An enthusiastic Mr. O Leary has assured the HSA that the UFASAS would be offered the same high quality fare currently as was currently available from Ryanair’s in-flight hospitality service.  In addition Mr O Leary stated he was keen to offer UMFASAS a wide range of onsite entertainment, scratch cards, gaming machines, pool tables etc.

Ms. Harney stressed that she expected the UMFASAS centres to function smoothly and seamlessly. They would be one stop shops she stated. She was bowled  over she said, something which even she conceded was well rather more than difficult,   by the support she had already received from the Pharmaceutical Society of Ireland whose members were lining up to take up franchises in the new centres. There was no doubt she added that there would be some patients who initially at least would be a little confused by the technology. The VHI however had been more than helpful and volunteered the services of their on line Nurse who would be available to give advice 24/7 to assist those in trouble.

For operational smoothness and efficiency it would be necessary to have an appointment system the Tanaiste said, this could be either accessed by text, telephone or online. The franchise for same has been offered to Ticketmaster.  Whilst attendance at UMFASAS per say would be free of charge, naturally enough booking, credit card and ancillary charges would of course apply. 

When contacted about the developments by Medicine Weekly, that well known expert on all matters medical Derek Davis gave the proposals a ringing endorsement.

It was high time he stated that Irish Medicine was taken out of the dark ages and he looked forwrd to experiencing these new developments first hand, though not quite yet. His only reservation was he said were on the subject of the catering facilities, but if needs must he felt sure he added that that his old friends over in Guillies would rustle up some tit bit for him and despatch it over by courier post haste.

Derek Davis

You have to listen to thunder and paper will take ink are well known clichés, but of course you don’t have to listen to the former or read the latter but alas unfortunately many do. And those amongst us who did either of the above over the week gone out could rightly be forgiven for coming away with the notion that the GPS of the nation were whiling their last days away in blissful ignorance, on crosswords, Sudoku, or practising their putting on the surgery carpet, whilst around them their practices were falling prey to cobwebs, beetles,

Silverfish and other creatures such creatures who thrive in neglected evironments. 

The world of general practice the media informed us last weekend, April 23, 24 was a wasteland in the last throes of self-inflicted death, or in the words of that self-appointed expert on such matters Derek Davis, a service industry inhabited by dinosaurs, who by definition would soon be extinct.

And what is the evidence, leading to the issue of such dire warnings of our imminent demise. Needless to say there is no statistical evidence, or even anecdotal evidence to back up these highly emotional and media friendly claims.  I have absolutely no idea what Derek Davis’s problems are, whatever they are I will certainly pray for him.   I think however that it is worthwhile for us to point out that General Practice is not a service industry but rather a profession and unlike our fellow professionals; solicitors, dentists, architects, accountants and the like, who I hasten to add also like ourselves for the most part offer an excellent professional service, we in general practice almost nation-wide, provide round the clock 24/7 cover.  And I stress  that for the most part this service is provided not by bought in locums, but by full time, fully committed, stake holder GPS.

This myth that has taken root that GPS do not provide out of hours service has to be scotched, and scotched at source before it gains any further credence.  Dublin is not and never will be Ireland. There may be a part of Dublin that is not covered by a  GP COOP , but it’s absence there should not deflect from the fact that the bulk of the country now out of hours is covered  and covered well by Co Ops and surveys of same have shown remarkably consistent very high customer satisfaction levels.  

Part of the latest GP bashing comes in the wake of a recent survey of A/E patients by Tribal Secta consultants which showed that 54 % of those who attended various city A/Es did not attend their GPS first.  By some incredible leap of the imagination this was then taken to mean that if over half the people who go to A/E don’t go to their GP first, and surely every really sick person must end up in A/E well then by definition almost, nobody must be going to GPS.   How wrong can one get? And I will expand on that point in the rest of this article.  But first of all let us cut to the chase.   The survey by Tribal Secta consultants was commissioned by the HSE, and every survey commissioned by an agency, no matter what the cost, will only see the light of day if the results play the commissioners tune.

That survey, the Tribal Secta survey had a brief, and the brief was to somehow spin a good light on the A/E service.  That this spin reflected badly on the only truly functioning organ of the health service was irrelevant. Political expediency was all that mattered.

The fact of the matter is that General Practice in Ireland was never as vibrant, as vigourous, as well organised,   as relevant nor as optimistic of its future as it is now, and certainly never as busy as it is today.  And that is despite the absence of any meaningful investment or tax breaks from the public sector.   And you know, I won’t say most, for the simple reason that GPS for the most part are doctors first and businessmen second, and of course depending on one’s perspective bearing this in mind one chooses ones physician, but it has to be said that over the past ten years or so a good chunk of GPS have invested heavily in their practices.

To come to any conclusions from the Tribal Secta survey that would have any statistical relevance to general practice was a flawed math from the outset; of course that was of no consequence to Mary Harney as all she was and is interested in is political gamelining.

To have any even vague statistical relevance the Tribal Secta survey ought to have been married to a contemporarionous survey of GP practices on the date in question.  And you know; of course I can’t say for certain, but I would hazard a fair guess in the case of the bold Derek Davis, that even if he didn’t pull his “I’m Celeb get me out of here card,” that he would get an appointment to see his GP, if he has one, and I would say that’s a big if, if not on the day well perhaps the next day.  My point being here that most likely his GP is very busy, but yet willing and business enough like enough to see old grumpy Davis within a reasonable time frame.  It is my belief that the Tribal Secta survey did not at all touch on general practice and therefore it cannot in its conclusions speak for it in any way whatsoever. 

To conclude let me say a few words in turn on A/E and general practice.

Fifty four percent of patients attended A/E directly without having seen their GP according to the HSE consultants Tribal Secta, but this means that forty six percent of A/E attendees did visit their GP in the first instance, something not highlighted at all in the recent media reports.  A/Es are are always jammed packed and from personal experience, in contradistinction to Derek Davis’s hearsay knowledge, I would hazard a guess that GPS refer no more than 1-2 percent of their daily consultations to A/E, thus the 46% of patients who almost half fill A/Es each day represents heavy workloads indeed seen by the nation’s general practitioners. 

Let us now look for a moment at the fifty four percent who bypass general practice for one reason or another.  Clearly some of these people do so for common sense reasons.  Obvious fractures or injuries definitely needing X-Rays ought properly to go to A/E directly, as also should large gaping wounds. The same of course can be said for serious chest or other acute illnesses where history or common sense informs the patient or those caring for them that hospital treatment/ admission is warranted.  Undoubtedly the lack of any meaningful effort on behalf of hospitals to collect fees makes attendance at A/Es attractive this is a HSE problem not a GP one.  And of course there is history.  Residents of the catchment areas of many of our hospitals, particularly our city hospitals have long histories going back generations, before blue card, not to mention the GMS or HSE were ever heard of, of using the local hospital as their general practice.  This is a practice which has never been properly discouraged. 

The Tribal Secta report makes a few correct statements but from them draws very erroneous conclusions, for example “Even where out of hours GP cover is available such as in Galway, this had no effect on A/E admissions, reflecting the HSE’s concerns that the system where GPS hire locums to look after their patients outside of office hours is not acceptable.”  I cannot speak of Galway but I do know that in Kildare we have an excellent co-op working extremely well with patient survey after patient survey showing extremely high patient satisfaction levels.  For the most part we work the service ourselves, but we do hire in additional staff mainly for the night shift, after eleven pm. And I hasten to add there is nothing wrong with that. If a patient having bypassed his GP co-op in favour of A/E gives the reason for his decision to do so as being that the doctor on duty is only a locum and would not know him,  have his notes etc.  I would take the view that this is absolute balderdash. Who does he think is going to see him in A/E most likely some intern or SHO with a fraction of the experience of the aforementioned GP locum.

There are many reasons for overcrowding in Naas A/E but if forced to pick one as being the most important I would have to plump for the obvious and that of course is the mushrooming of the population in its hinterland  over the last decade or so which continues unabated, a situation replicated almost nationwide.

The Tribal Secta report criticises GPS for referring patients to A/E for diagnostics tests and where OPD appointments are not being provided in a timely manner. This in the immortal words of one CJH is an answer to an Irish problem. Furthermore it is not only morally correct but also most likely medico legally and medical councillary mandatory.

To conclude let me just say that it does seem rather ironic that when yes, we do have an

A/E crisis, nobody could argue with that, and yes  we do have severe OPD problems with waiting in many specialities verging on the ridiculous,  and yes we do have a bed crisis with many consultants, particularly surgeons left almost idle because they have no beds in which to place their patients,  and yet with all these problems what do we do but find fault with the only part of the health care system that is actually working.

And if anybody is seriously trying to find out how well or how badly general practice is working let them go and do their surveys at the coal face, in general practice.  It is not only a nonsense but disingenuous in the extreme,  a gross  sleight of hand, an appalling  act of cute hoorism to survey a self-selected cohort of individuals who for whatever reason have bypassed their GP; and I have dealt with a number of such  possibilities,  and to extrapolate from this self-selected cohort and from this extrapolation to draw damning conclusions pertaining to general practice without also including in ones figures the huge numbers of patients who do visit their GP and are happy to do so.  Out of flawed math what truth can come?

PS:  This am April 26, I received a correspondence fom Tallaght hospital in relation to a referral I had sent for an orthopoedic appointment for a 13 year old girl, and I quote “I hereby return your referral letter. Unfortunately Tallaght does not have a facility to accept outside refferrals to the orthopoedic clinic.  And Mary Harney, Derek Davis and the rest of them give out about GPS referring patients to A/E, or patients referring themselves!!!!!

Medical Council Warnings

The Irish Medical Times, April 14 carries and interesting front page article which draws attention to a situation which could have very serious implications for hospital doctors; which the piece deals with, but also by extension for general practitioners.  This piece by Greg Baxter tells us that The Medical Council will hold consultants accountable for the safety of discharged patients, even if hospital management have put pressure on them to free up capacity.  The Council’s vice -president Dr. Colm Quigley is quoted as saying, “If a doctor discharges ill patients, then it is on the doctor’s head, not on the administrator’s.  The argument that a doctor felt forced by management to discharge ill patients will not work in a Fitness to Practice hearing.”  The president of the Medical Council Dr. John Hilley is quoted in the piece as saying that doctors must be able to stand over their decisions, “Being told by an administrator to discharge a patient does not constitute a clinical decision. “

Clearly hospital doctors of all ranks must look very seriously at these statements coming as they do from the top echelons of their ruling body, the Medical Council, for failure to heed these warnings not alone will expose them to censure or worse by the Medical Council but almost certainly it will also leave them wide open to litigation, a possibility which has already become almost inevitable on the heel of the words of warning issued by the council. 

Hospital doctors expose themselves to censure and litigation by being brow beaten into making over-hasty discharges, or indeed failure to admit in the first place by overcrowded hospitals and overzealous administrators.  General Practitioners also expose themselves however to such dangers by taking too much cognisance of warnings of bed shortages, casualties over flowing with full trolleys and wards closed due to seasonal vomiting virus, none of which will act as a defence I should think in the case of a GP either being sued, being brought before the medical Council or most likely both, in the case of a patient who came to grief or perceived grief because he or she was not referred to hospital.  General practitioners when wrestling with the decision of whether a patient should or should be referred to A/E should as far as possible exclude the issue of overcrowding in A/E from their calculations. Failure to do so, could come at a very great cost.  The situation with regard to referring patients for OPD appointments also deserves consideration.  If the Medical Council feels, as it does, that “If a doctor discharges ill patients, then it is on the doctor’s head, not an administrator’s,” then what is the Medical Council’s opinion with regard to patients having being referred for OPD appointments by their family doctor, being offered appointments to see the selected consultant at very often ridiculous dates way into the distant future.   Every GP is familiar with the situation whereby having sent off a referral letter for a patient the patient returns sometime later with the appointment card and with a rather bemused look hands it to the GP saying, “remember that letter you sent off for me to be seen in the hospital, well this came for me today.”        

“Ah! Yes,’ you say perusing same, “Sept. 4th. Three months away that’s not too bad”

“Eh! Doctor would you mind checking the date again.”

“Yes I see, Sept. 4th. 07.” And when we consider here that most public OPD appointments for some time now have only been issued upon receipt of a GP’S referral letter; which presumably the consultant is supposed to read and consider prior to issuing an appointment date, what I wonder is the Medical Council’s opinion of consultants sanctioning appointments for newly referred patients, 15 months down the line.  Or indeed what is its stance on the same appointments being scheduled 12, 6, or even three months later. 

It is my view that consultants standing over appointments rostered at some point in the distance, way over the horizon, could well be placing themselves at risk if not at the hands of the Medical Council, well certainly at the hands of litigants.  And as in the case of the early discharges, the administrators, departmental mandarins and politicians ultimately responsible for the mess will always manage to remain unaccountable.  And of course very  often GPS when needing  a  further opinion and  knowing that an OPD appointment will be given simply too far into the future, resort to the only option open to us and that is referral to A/E.  Not by any manner of means the ideal option, but alas the only one.

When is an OPD appointment and OPD appointment? I am speaking here of referrals in the first instance only.  It is my view that to be of any real benefit for the most part GP referrals ought to be seen within a couple of weeks, a month tops. Clearly some patients must been seen earlier still. 

Giving OPD appointments three, six, twelve months down the road, is not in my view offering the patient an OPD appointment for the treatment of the ailment for which they were referred. By then the ailment will either of have been cured, resolved itself, advanced beyond help or killed the patient