Trust and respect

Relationships are about trust and respect. Whether these two components will appear in forthcoming negotiations about a new GMS contract for GPs is yet unclear. It is a pity that trust has to be established from an all time low, between GPs and the triad gang of Government, Department of Health, and the HSE. It is also a pity that GPs have felt let down by their union representatives in recent years.

But that is life and we must get on with it. It seems it has to be said that GP unions need to work together towards a common good, even if it might feel like a Fianna Fáil and Fine Gael coalition of the pragmatic but nervous unions.

The new kids on the block, the NAGP, were born out of a need for GPs to find a voice that represented them and which hopefully they could trust again after many felt so let down in the last few years by the IMO. A sense developed that deals and agreements were made over the heads of the everyday GP. Both organisations represent a sizeable part of the GP brotherhood and sisterhood of course. Hopefully, both organisations have learnt that an Arab Spring or rebellion will always be necessary if those on the top of the pile don’t listen to those being led. Because none like being led less than a profession who spend their days making life and death decisions with patients, not for patients. GPs know what they want and the ideas of a few should not be put ahead of the ideas of the majority. The majority now want out of the expectation to pay out of pocket for after-hours.

As the recent Ploughing Championships this year in Tullamore highlighted, two strong horses pulling in the same direction is far better than the chaos of two horses pulling in opposite directions.

One of the big decisions in these negotiations must be the future of after-hours care, the red-eye shifts, the weekends, and unsocial hours. This care has been taken on traditionally and historically by the medical profession in responding to a need for emergency care in rare and unusual circumstances. Somebody had to do it and the medical profession responded with compassion and pragmatism to a need. But this was in an era of a different kind of respect for doctors and a different response by society to mistakes, mishaps and tragedies in medical care, by doctors, doing their best, within impossible systems.

Greater and often impossible expectations of the medical profession means that after-hours, as well as day care, is no longer a reasonable response to this need. Society at this stage now wants the convenience of after-hours care for even minor care, while at the same time not wanting to pay the appropriate cost of delivering this care. Where a doctor may have been called once on an occasional night in the past for genuine emergencies in a non-litigious era, the public have a modern sense of rights and entitlement to care at any hour, without thought to the doctor, who has been stretched all day in his or her surgery.

The Irish system pays doctors the same per patient whether it is 11am on a Sunday morning or 3am on a frosty Monday morning, whether it is a bank holiday or a normal day. So after-hours can no longer be taken for granted and it must become optional, like other modern democracies. Yes, doctors will continue to look after and be available for patients in after-hours care, but this area of care must be acknowledged for what it has become: The emergency department of community health; under-resourced, under-appreciated, and dangerous for all involved.

A doctor who worked in the US army in Afghanistan said she was scared at first, about the danger she was in, but since working in US hospitals after this she said she felt more fear. In Afghanistan, she felt that her team were looking out for her back, whereas in hospitals back home in the US, she felt that her back was very exposed by management and legal policies that leave doctors very vulnerable. Feeling more vulnerable than a war zone!

This is the increasing experience of doctors in Ireland. The health system is out to undermine rather than support, blame afterwards rather than listen beforehand. Expect more when too much has already been given. Appreciation… what is that? This has to stop.

On top of this are wieldy bureaucratic expectations that are imposed on doctors with little thought to the effect this red tape has on the health of both doctor and patient. Excessive red tape has no accountability, while doctors have many excessive and undermining processes imposed under the false cover of accountability. After a certain point ‘accountability’ takes a negative toll on spiralling medical costs and health outcomes.

So these negotiations must finally be about reasonable expectations and develop systems that ‘flow’ and that work for everyone, not just for managers, accountants, politicians, and lawyers. We need some form of Ombudsman to work with the medical profession and managers to undermine waste, counterproductive practices, and bullying in the health sector. To understand and push constant change in health systems that are needlessly complex and wasteful. Bring back some of the old pragmatism and wisdom of a good vet or a country GP.

Get back to basics. Keep it simple. Doctors know what doctors do best. Managers do not. As Minister for Health Simon Harris has conceded in regards to Waterford cardiac care, it is dangerous for politicians to decide on clinical matters and clinical priorities.

Trust and respect is what is needed between all the parties. Otherwise negotiations have no meaning. And unless we get it right, patients will be the most vulnerable. As with war, where refugees are killed and need to flee, Irish patients die and are underserved or choose to flee the Irish health service, as indeed many Irish doctors and mature GPs have already done in leaving these shores.