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!!!!!