“Young, well trained GPs are leaving Ireland. We are an ageing group – many plan retirement as soon as is feasible... yet this contract would require increased numbers of GPs and of other staff.”

“I am already overworked. So I cannot fit in all the inevitable unnecessary consultations that would happen. My existing patients would inevitably have to wait longer.”

“The HSE can change anything they like in the contract provided that they give us notice. What kind of a contract is that?”

The above quotes give a flavour of the feedback members have given to the College in recent weeks about the contract document for the planned scheme to provide free GP care to under sixes, presented to the GP organisations by the HSE and Department of Health at the end of January.

The ICGP felt it was essential that the College would understand the views of its members before representing a particular position on the document. The views of members are incorporated in the College’s submission to the Department of Health and HSE on the contract proposals.

As regards mapping out the future of Irish general practice, the response of members and the College leadership can be summed up as: “well, I wouldn’t start from here.”

The basic message from the College executive and members is that the Government should withdraw this draft contract and engage in meaningful discussions with GPs on formulating a proper change programme.

The consensus is that the contract document as presented is insensitive to the needs of GPs and to patient care, in addition to being largely incoherent, confusing and unworkable.

The College has stressed that economic and workload factors have made this a time of unprecedented challenges for general practice. The ICGP is of the view that the contract proposals do nothing to address these challenges and, if implemented, would actually make things far worse for many GPs.

CEO Kieran Ryan says the launch of this draft contract – without any consultation with the profession and with its lack of clarity and balance – will no doubt create further fears for the future of Irish general practice.

The College says it anticipates further engagement with the Department of Health and the HSE over the coming months, in the hope that more realistic proposals for the future development of general practice and primary care can be developed.

In a preamble to the contract document, the HSE/Department say it provides a “unique opportunity to reorient the focus of primary care towards active health promotion, disease surveillance, prevention and appropriate management of chronic conditions, in addition to diagnosis and treatment. It is well known that the majority of chronic conditions are related to a small number of lifestyle issues, which if modified would avoid these conditions. Primary care is centrally positioned to lead this approach.”

Not many GPs would disagree with these sentiments. However, the devil is in the contract detail and the College and its members’ examination of the draft contract has unearthed what they feel is a wrong-headed and overly bureaucratic approach to achieving these laudable goals. 

The College believes the draft document, as a blueprint for the future, fails on practically all counts. It is deficient in areas of clinical appropriateness; patient-centredness; quality and safety of care; evidence-based and outcome-focused care, patient privacy; clinical independence of GPs; and it may even threaten the future viability or sustainability of a GP service.

In its detailed response to the document, the College has made some key points:

• The draft contract is not deliverable with current available manpower, infrastructure and resources. The expansion of ‘free’ GP care to an additional 240,000 patients could destabilise current service delivery, which is already working at full capacity
• The draft document tries to cover all eventualities and absolve the HSE of any responsibility for service delivery. “If the Government is serious about putting primary care and general practice at the centre of the health service then it needs to show a commitment to doing so. The contract in its current form will not meet that aim.”
• The implementation of universal GP care without fees for children under six should be placed in the context of a comprehensive and holistic programme of care for this age group, which would focus on the network of care services needed to achieve effective outcomes
• A key flaw too has been the consultation process, or lack of it, on the plans to extend free GP care at the point of access. The College believes the Government should engage properly with clinicians and their representative organisations across the sector to properly plan for the implementation of this most fundamental of healthcare reforms. 

The College’s submission stresses the need for a ‘coalition of stakeholders’ engaging in a partnership process to achieve change. The ICGP has emphasised that it is not opposed to the concept of GP care free at the point of access. The provision of GP care for all, based on medical need and not on ability to pay, is a strategic vision of the College.

The College says there is a clear need to engage with the profession to make this a reality with the best possible outcomes for all. However, a key unmet need in the management proposals to date is the lack of any realistic plan to address the resource gap in general practice at the moment. 

The College says the level of funding outlined by the Government for this programme (E37 million in 2014) is a gross underestimate on what such a programme will really cost. There has been no discussion on and no outline of how HSE and primary care team resources are to be improved to deal with the need to access non-GP clinical services.

The College points out that the last three rounds of FEMPI cuts were crude and ill-thought-out, and have left a very shaky foundation on which the Government hopes to build a free GP care system at the point of access.

Worse still, the College argues, is the fact that proposals are being drawn up for this new scheme against a background of cuts to medical cards, including discretionary cards, which is a source of considerable concern to GPs.

The ICGP stresses that the new scheme must not be funded on the back of savings from medical card cuts.

Another major issue is the timeline for the introduction of the new scheme – the ICGP says making major changes too quickly could actually worsen services.

Drilling down into some of the details in the document, a number of flaws have been highlighted by members as part of the consultation process. These include:

• The defined five-year duration of the contract, which has led to concerns about continuity
• The proposed right of the HSE to assign a patient to a GP, without reference to the usual right for the patient to choose a GP. There are also concerns here about current rules on accepting or referring patients
• ICGP guidelines on practice premises are referred to in the document, although these College guidelines do not currently exist and the College is reluctant to get involved in this area. There are concerns that there is no mention of the HSE’s obligations regarding standards of premises, in addition to concerns about resources needed to maintain premises to particular standards
• Section 13 of the document encompasses a completely different range of services to that currently provided  by GPs under the GMS contract. Health surveillance and promotion, for example, are complex activities requiring professional staffing and resources that are currently outside the normal capacity of general practice, but this is not recognised in the document
• Section 15 on hours of availability requires complete revision, as in effect they require GPs to work 70 hours per week, which would not be sustainable or safe
• Section 16.5 on the right of the HSE to inspect and obtain full GP records may be contrary to data protection rules
• Section 19 on performance review indicates a conflict between the proposed role of the HSE and the current role of the Medical Council in regulating doctors. The rights of the HSE to probe matters concerning the Medical Council are questionable
• Section 28.4.4, stating that a GP shall not do anything to prejudice the name or reputation of the HSE, potentially conflicts with a doctor’s right to advocate for patients where necessary.

The College notes that the document places enormous, and in some cases inappropriate, responsibilities on the GP, with little or no ‘quid pro quo’ from health service management. The obligations of the HSE to provide the necessary resources to enable the delivery of the aspirations of the draft contract will need to be included, according to the ICGP.

Not only does the document fail to focus on the resource needs of GPs, but it is not even patient-centred, the College believes. It is ‘heavily focused on bureaucracy and the administrative requirements of the HSE, which outlines ‘unquantified’ admin duties which are subject to change by the HSE at its discretion. This, the College says, will impact on proper GP service provision.

Also, the emphasis on performance monitoring and patient data reporting are not related to patient outcomes.

The proposals also, the ICGP believes, raise legal issues as to whom exactly GPs are ultimately accountable to. There is a potential conflict between traditional accountability to the Medical Council and the proposed HSE contractual accountability.

Added to the bureaucracy is a potential confusion and inherent conflicts in service provision, as the specific contract for under sixes care differs considerably from those GPs hold for the provision of other services. Another potential flaw in the proposals, it is felt, relates to the major role outlined for primary care teams, given that the current PCT network is largely ineffectual and poorly resourced.

Such are the flaws in the draft contract, that the ICGP believes what is needed now is a complete restart to the whole process, and a proper engagement by health management with GPs and patient groups.

The College believes the draft contract is clearly part of a process to address a full GMS contract for the whole population, given that the Government’s plans are eventually to introduce universal free GP care. The overall feeling of College members about the document is best summed up by the comment of one member during the consultation process: 

“This reads like a document you would give an enemy rather than a partner in the provision of healthcare.”

The draft contract is available at: http://www.hse.ie/eng/about/Who/gmscontracts/under6GPcontract/draftcontract.pdf

The College’s full response is available on its website www.icgp.ie