We are led to believe and indeed most are of the opinion that there are significant problems with the establishment of modern medicine as it exists today. In general terms there are two kinds of medicine in Ireland; community and hospital medicine, and each area has its own assortment of 'problems'. There is no shortage of solutions, and the usual form of a solution is the one that might afford the greatest benefit to the individual or group proposing the solution. The present Governments solution is from the old formula of the free pint, and the carrot of free GP care is repeatedly dangled in front of the public nose. What both the problems and the solutions lack is the ability to look at the Health Service from an entirely objective vantage, and to be prepared to accept that we ourselves public and professionals are as much a part of the problem as the entity at the end of the pointed finger.
In respect of General Practice a significant portion of the 'blame' for our grossly inadequate system of community medicine lies fairly and squarely with the body responsible for training General Practitioners. As Bertrand Russell states of philosophy, the same can be said of a College or institution, in that 'the highest compliment one can pay to a philosophy is to be brutally and objectively critical of it', yet criticism of Irish institutions is rarely met with introspection and usually met with consequence for those making the criticism. In many respects Ireland has never evolved out of its status as a colony, we remain a subject people in need of masters and the Institution, be it the Banks, Medicine or the Legal profession remain our masters. We wouldn't have it any other way.
At present there exists two medical systems in Ireland; community and hospital medicine, and most of the problems within one system are a consequence of the problems in the other. Waiting lists for procedures, overcrowded casualties, ill-affordability and lack of services in the community, are all related by the simple reality that there is no clear distinction between hospital and community medicine. The dogs on the street are aware that an enormous portion of the 'treatment' that occurs in the hospital could easily be conducted in the community; here we are all in agreement. Where the conflict and antagonism begins is when we attempt to discern why this should be so, and how it might be remedied.
Realistically we will never be capable of implementing community or hospital services unless we can arrive at a satisfactory answer to this question. I assert that the answer is twofold; GP's do not manage community medicine properly because in the first instance they are not trained or confident enough to do so, and secondly because they have not the time, are not inclined or incentivised to do so.
In the first instance the lack of training is the fault of the ICGP, the Medical Council, and the Medical Colleges, and the second part of the problem is the fault of; the State, the patients and the GP's themselves.
The Colleges.
After medical school and a one year internship at the hospital, What to you have to do to be a GP in Ireland? The answer quite surprisingly is Nothing! Any medical graduate on the General Register can hang a plaque on the wall and practice as a Private GP. He or she can work in the out of hours service (largely staffed by non specialist trained GP's), he or she can provide locum cover, or be employed at any GP practice in the state. Indeed were it not for the army of non specialist trained 'GP's working in the Irish system, community medicine would very likely collapse.
So what is the point or the purpose of specialist GP training in Ireland? In a fundamental and practical sense the only purpose of specialist training in Ireland is that a GP might be eligible for a 'medical card list' whenever such lists rarely become available. Non specialist GP's can see and treat medical card patients anywhere and at any time throughout the state, however to obtain formal 'ownership' of a list of such patients one must be a trained GP. It's an entirely Irish solution to an Irish problem, that has everything to do with money and nothing to do with medicine.
The actual end purpose of specialist training and the specialist register in the Context of General Practice exists solely to control who can access the lucrative medical card system. It is a means of reducing the numbers amongst whom the cream-pie must be divided. Once again it is reasonable to reiterate that the only difference between a member of the Irish College and a non-member is the ability to own a list of medical card patients. In practical medical terms both are fully licensed to practice in the exact same manner and see exactly the same patients. The difference is one of ownership, possession, contracts and quite simply, money.
In practical terms if the end result of General Practice training amounts to little more than entitlement to the lion's share of the community health budget, we should not be surprised to discover that General Practice training in Ireland is entirely lacking, and to a great extent irrelevant to the actual practice of community medicine. For example a significant majority of presentations in General practice have a psychological or psycho-social component, whilst General Practice training in Ireland includes merely the 'option' of a six month psychiatric post. Dermatology waiting lists in Ireland (mostly in the hope of a simple biopsy) are quite possibly the longest on the planet, and not surprisingly one could complete formal general practice training in Ireland without ever once having picked up a scalpel.
Many Irish GP's simply “do not suture” and GP's who work at the out of hours service in Dublin are specifically asked not to suture. Not because of hygiene or the usual palaver about infection control, but rather so as “not to set a precedent” . Undoubtedly most of the GP Members at the out of hours service are also Members of the ICGP and yet, how one could maintain ones membership of a college, fulfil the various requirements for continued education, and still remain unable or unwilling to close a simple flesh wound, is beyond incredulous, and speaks volumes in respect of our health service.
The disparity between training and the actual practice of Community Medicine is not only a product of the non-clinical and entirely financial endpoint of the process, but is highlighted by the fact that so many General Practitioners provide an exemplary level of care to their patients (including suturing) without any formal training in General Practice.
Unless General practice training becomes focused upon the task of producing community practitioners capable and competent in the provision of relevant community health services, we will continue to burden the hospital with that which could easily be managed in the community.
The Patient
Not being eligible for a Medical Card list, my practice is entirely private. I have in excess of 1500 patients and at most I see between 5-10 patients per day (from whom I extort the relatively modest fee of €50 a visit). I have worked for many years at practices with a significantly smaller number of medical card patients and yet I would see 20-30 medical card patients per day.
We don't like to talk about this reality because we are not fond of truths in Irish medicine, however the simple reality is that medical card holders present more often to the GP simply because the service is entirely and completely free, and when something has no price it has no value. Therefore if much of the practice time is spent entertaining frivolous free-consultations, there is little time to actually treat people. This reality is complicated by the fact that many practices are entirely dependent upon their Medical Card incomes, and as such will scarcely rock the boat upon which they sit, regardless of the fact that it might be full of holes and sinking fast.
How community medicine will cope, or whether it will survive the Minister's promise to turn every patient in the country into a medical card patient is beyond comprehension, but in traditional Irish style, it sounds great, and is a clever evolution of the Haughey (Ha Ha) era...'vote for me and I'll buy you a pint' or in this case “free” GP's visits.
The state
The state is probably the most significant contributor to the problems of Irish medicine, however this reality is at once complicated by the fact that the state is a product of we the people, of vested interests such as the medical establishment, the HSE, and of the gullibility of the people to swallow empty promises and accept quangos and bureaucracy as the end result of those same promises.
Unfortunately the state lacks the courage to draw an appropriate distinction between; the nursing home, the hospital and General Practice, and as such it allows the most expensive component of the trio... (the hospitals) to function in the capacity of providing care on all three levels. Not only are the hospitals incapable of doing this, but they must also expend stretched resource upon the education of fee paying medical students. Incidentally the fees being paid by almost a thousand medical students at Beaumont hospital are in excess of 35,000 per anum, all of which is paid to the registered charity that is the RCSI.
In short the State presides over a medical system where General Practice does not fulfil the needs of the community, the hospital cannot supply hospital services, and the state will notprovide a distinction between the two.
The GP's
No problems here, we are all perfect?
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