Irish Medical Organisation

Mr George McNeice - Address by Chief Executive AGM 2012

Text of Chief Executive's Address to IMO AGM 2012

President, Members and Special Guests

As always, it’s a great honour for me to address our Annual General Meeting and I want to begin by expressing – on behalf of all my colleagues in Fitzwilliam Place and on my own behalf – our appreciation for all your support for our work over the past 12 months.

As I said in this year’s Annual Report, this organisation exists to represent, defend and promote the interests of doctors across the country and to promote the development of a caring, efficient and effective health service.

In pursuing those objectives, the AGM has a critical role to play.

  • As the formal policy making body of the organisation, it allows us an opportunity to review the strategies and tactics we employ to meet those objectives and to review our priorities for the coming year.
  • It gives members a chance to improve their knowledge and skills for their own benefit and the benefit of their patients.
  • It provides us with a wonderful social occasion and an opportunity to reconnect with old friends and colleagues.
  • And, perhaps most importantly, as the only Trade Union that represents doctors across the health services, the AGM gives us an opportunity to step back from the pressure of our daily lives and take the pulse of our members from across the country.

This year – as ever – I’m struck by the enthusiasm, the passion and the energy of our members.

And I’m struck by the commitment which has brought so many of you together for this weekend despite all the pressures and the competing demands there are on your time. That’s very heartening.

But I’m also struck by a real sense of concern and despair amongst members at what is happening to our health services and the direction we’re being led in by the HSE, the Department and their political masters.

A year ago we were delighted to welcome the new Minister for Health, Dr. James Reilly, to this conference and we listened carefully to what he had to say to us.

Like people across the country we were very optimistic at the election of the new Government.

We were optimistic in particular that the new Government would be bolder in its thinking than its predecessors had been….that it would be more respectful in its dealings with our members and with this organisation …..that it would be more honest in its assessment of the challenges and the solutions required and that it would be more dynamic in the pursuit of much needed reform.

Twelve months on, I know I speak for very many people here today when I say that judged against those expectations, the past year has been very disappointing.

The optimism and enthusiasm of a year ago has all but disappeared and the overriding impression now is of how little has changed since the new Government came into power – not how much.
This Government is never slow to remind us that they are dealing with huge financial problems for which they were not responsible. There is no disputing that.

And we agree that those financial problems must be tackled and resolved. Every day our members see the impact of this financial crisis on ordinary people – people who had nothing what-so-ever to do with bringing it about:

  • Our members see the misery and stress faced by those who have lost their jobs or who live in fear of losing them.
  • They see the increasing desperation of people trying to make less and less go further and further and how that corrodes their quality of life and their health.
  • And they see their ability to help their patients come under massive pressure as resources are pared back, beds are closed and services are withdrawn.

So this organisation doesn’t need lectures on how serious our financial crisis is. Our members deal with it every day of the week.

But a year on, it’s simply not good enough for the Government to keep harping on about the country’s challenges or who was responsible for creating them. A Government is elected to solve problems not to hide behind them.

And a year on, the problems have not been solved. Worse - there is little confidence that the right progress is being made.

Nor is there evidence of any significant change in the attitude of those running the Department and the HSE:

  • These two bodies continue to bury their heads in the sand in terms of the manpower crisis we’re facing across the profession.
  • They continue to drag their heels when it comes to implementing agreements.
  • They continue to pick fights with individual doctors in different specialities wasting their own time, the doctor’s time and our organisation’s time as we get them to do what they should have done themselves in the first place.

So the optimism of a year ago has given way to renewed worry and doubt about what the future holds for doctors and other health professionals and for our patients.

One of the problems of course is an absence of leadership.

The Government was elected on a platform of change but has repeatedly opted for the status quo – of course the loser in that situation is the patient.

The theme for this AGM is Our Patients – Our Priority. This reflects the fact that it is the plight of patients which is uppermost in our minds.

The IMO has consistently advocated for reform in our health services not as an end in itself but as a means to improving the experience and the quality of life of patients across the community.

That patient experience still leaves much to be desired –

  • A two tier health service where neither tier now commands much respect and both tiers appear to be in danger of collapse.
  • Delays for procedures and treatments which could transform lives and empower people.
  • Inefficiencies leading to stress and pain.
  • And, perhaps most cynically, roadblocks put in the way of those seeking their legitimate entitlements and reliefs.In Opposition, members of the current Government never tired of speaking about the deterioration in our health services and the need for a radical overhaul. Some people – including some who should have known better – held out the prospect of easily implementable reforms transforming the patient experience.

In Government the promise of those reforms has become bogged down in the carpets of Hawkins House.

The mandarins who have spent years defending the indefensible and formenting division and tension … are winning the key arguments and we are stuck in crisis management when what we need is crisis resolution.

We’ve seen that in so many ways over the past twelve months in relation to issues like:

  • The farce over the administration of the medical cards system - where tens of thousands of applications got stuck in a jam that is taking months to resolve.
  • The failure to fully engage with the Croke Park Agreement where every constructive suggestion is coming from the Union side with none at all coming from management.
  • The chaos in relation to NCHD posts where the Department has created a revolving door – chaotically trying to fill the positions vacated by the graduates it is forcing to emigrate.

Flann O’Brien couldn’t have conceived of a better farce.

The IMO believes that in the face of this chaos and mismanagement, it becomes even more important that we remain consistent, realistic and resolute and we will continue to do so.

In doing so, we understand two things that are very empowering.

  • Firstly we understand that reform is necessary and inevitable. The status quo is simply not an option.
  • Secondly we understand – perhaps better than other players in this area – that the only reforms that will work are ones in which doctors and other health professionals are treated as partners with the respect and honesty which partners deserve.

Over recent years we have given much thought to what key principles should underpin any reform proposals for the health services and our confidence in those principles has not wavered.

Tomorrow we will be launching a paper on the market model of healthcare – called Caveat Emptor or Buyer Beware.

This paper explores market failures in healthcare and highlights the negative consequences of competition in both the private health insurance market and the health care provider market.
It looks at the experiences of competition in the United States and the Netherlands and our own experiences in Ireland.

We have serious reservations about a free market model of health care and we believe that the Dutch experience which is so often quoted by the Government needs much closer examination before we can truly say whether it is a suitable model to import into Ireland.

For example, health care costs continue to rise in Holland, the number of insurers has fallen - with just 4 now controlling 88% of the market - and competition has had little positive impact on the quality of care.
Let me be clear. The IMO supports the concept of Universal Health Care. We have spelt out clearly the principles which we believe should be at the heart of the system including equity of access, quality of care, clinical autonomy, choice and mobility and so on.

But there is much to be debated about how Universal Health Care can be applied in Ireland and tomorrow we’ll be calling for an urgent white paper on the issue so we can have a proper debate.

We’ll also be urging the Government to carefully consider the negative effects of competition on healthcare in terms of access, choice, quality and affordability.

And we’ll be asking the Government to respect the nature of the Doctor-Patient relationship which is not commercial and which must always view patients as persons undergoing medical treatment as opposed to persons purchasing goods or services.

A key principle of the IMO is that our health services should be built on the basis of equality.

The argument that we’ve created an unequal society in Ireland is unassailable. But our paper on Health Inequalities and our Scientific Session yesterday highlighted what that means for ordinary patients;

  • Lower life expectancy for people born in less well off areas – a difference of amost four and a half years of life between men born in deprived areas and those lucky enough to be born in the country’s most affluent areas.
  • An even greater disparity in life expectancy of up to 6 years between those lucky enough to work in the professions compared to their unskilled counterparts.
  • Higher mortality rates amongst those living in local authority accomodation compared to those living in their own homes.
  • And higher levels of obesity, diabetes, smoking related diseases and Coronary Heart Diseases depending on which socio-economic grouping you belong to.

The harsh reality is that in Ireland in the second decade of the 21st Century…as we approach the centenary of the 1916 rising, the proclamation of independence and the promise to cherish all the children of the nation equally…. the health, the life expectancy and the quality of life of our citizens continues to be heavily influenced by what socio-economic group they happen to be born into.

Our paper argued that addressing these inequalities is not just the right thing to do morally….it is the right thing to do economically and financially.

Inequalities in health account for about 20% of health care costs and 15% of social security costs across Europe. Reducing them will directly help the productive capacity of the economy as well as reducing costs on the exchequer.
Reducing costs and increasing efficiencies of course is almost all we hear about these days.

The negotiated vehicle for this agenda in respect of the public service is the Croke Park Agreement and I want to say a few words about this Agreement.

Firstly it’s important to state again that we signed up to the Agreement because we believe it offers an opportunity to promote beneficial change in the health services at a time of national financial crisis.

The Agreement continues to be the subject of much criticism and scorn – unfairly so in my view.

In recent weeks, PJ Fitzpatrick - the independent Chairman charged with overseeing the implementation of the Agreement – testified to its success at the Public Accounts Committee and told of the extent to which it is facilitating change and reform and efficiencies on a basis of co-operation and partnership.

Mr. Fitzpatrick outlined how – in its first year - the agreement had benefitted the Exchequer by over €680 million through savings, reduced waste and increased efficiencies. He went on to predict that as a result of the Agreement almost 70% of the targeted reduction in public service staff numbers by the end of 2015 would be achieved by the end of this year.

These are very important achievements but they do not get the credit and support they deserve and there are still some people who would prefer to see tensions and disputes rather than negotiated progress and co-operation.

I would now like to turn to matters on which we will focus in the coming year in line with our Corporate and IR strategies. We have a busy agenda of work ahead of us.

Representing and supporting individual members who are in dispute or who require help to ensure that they can get their proper entitlements is at the heart of what we do.

A year ago we revamped our industrial relations machinery and established a Personal Cases Unit to ensure that we were adequately resourced to meet the growing demands of our members.

That investment has dramatically improved the service we can offer and I know that members everywhere have appreciated the improved responsiveness and effectiveness of this team.

Within the first six months we responded to over 15,000 queries from members across the specialty groups. We will continue to prioritise this critical service for members.

At national level there are many issues affecting the speciality groups.

I’ll start with General Practice which has been one of the outstanding success stories of the Irish health service for generations. It is known to all as patient-focused, easily accessible in both urban and rural areas, highly professional and very cost-effective.

However General Practice is at a cross roads on a number of fronts as a result of decades of political interference and the mismanagement of necessary reforms.

  • Firstly it is creaking under the weight of the additional work which is being thrown at it; the GMS contract never envisaged GPs managing warfarin clinics, supervising phlebotomy services or running diabetic clinics yet the HSE tries to force GPs to provide these services without any financial support or resources.
  • Secondly, the financial model underpinning the service is close to collapse as GMS fees are cut unilaterally under FEMPI and the recession causes private practice fees to fall and GMS patient demands to rise.
  • The service is facing a manpower crisis as increasing numbers of the next generation of GPs opt for more attractive and more rewarding opportunities in other disciplines and other countries.
  • This is going to be exacerabated in rural Ireland where the Government seems intent on collapsing the service through measures such as the withdrawal of distance coding for patients - without any acknowledgement of the problems facing patients and GPs in rural Ireland where public transport services are often non-existent and local hospitals are also being closed down.

Fundamentally neither the Department of Health, nor our elected representatives seem to have any appreciation for either the crisis facing GPs or the gap which is emerging between what GPs have been contracted and resourced to do and what they now expect them to do.

This Government professes to have ambitious plans for General Practice. They talk of free GP services for all…GP visit cards for Long Term Illness book holders and a revamped service based on Primary Care Teams.

But there is a yawning gap between the talk and the action that follows.

One only has to look at the chaos around Primary Care Centres.

Policymakers promised a transformed General Practice based on a fully resourced, nationwide network of Primary Care teams in special centres delivering a state-of-the-art service. But instead they have created a mish-mash of “virtual” teams without proper resources or funding.

In the few areas where centres have been established, the State has shamefully stood back and encouraged GPs to invest heavily in infrastructure and then used the recession to achieve deals and rents that undermine the very viability of those developments. In other areas the State stands idly-by as banks decline finance necessary to develop centres.

The notion that in the depths of the greatest recession in this country’s history that the State should expect the private sector to deliver Primary Care infrastructure is madness. It isn’t working and it won’t work.

So let’s stop the empty talk and see some proper action. For example could the State use some of the thousands of empty buildings it has at its disposal now - either in NAMA or through the failed decentralisation project - to make proper facilities available on a nationwide basis.

Surely that would make more sense than simply throwing more work at an already overburdened service.

Change and progress can happen but not if the Government refuses to work with us as the representative body for GPs.

Let me take the Long Term Illness scheme as an example.

We know that there is a compelling case to use the GP service for long term illness management but we won’t be party to a solution which forces additional work on to an overstretched service without proper resources and financial supports being made available to ensure it works properly. Allowing that to happen would be bad for our members…..but it would also be bad for our patients and we won’t allow it. As a former President of this Organisation, I have no doubt that Minister Reilly knows this – and I hope he knows too how determined we are on this and other issues.

The issue of representation continues to distort our relationship with the Government. Four years ago we sat down with the Government in the Taoiseach’s office to hammer out a deal to get that Government off the hook they had hung themselves on over Medical Cards for over 70s.

That day they looked us in the eye and gave a solemn undertaking to amend Section 4 of the Competition Act so as to allow the IMO to fully represent its GP members - in the public interest - without threats being held over the organisation or its officers and executives. That undertaking was renewed again in the Croke Park Agreement but still we have no progress.

Instead the politicians take their counsel from civil servants who have failed to grasp the fact that engaging with this organisation is the only way in which they can hope to make worthwhile, sensible progress on improving the GP service for the benefit of patients.

Time and again the GPs and the IMO have come to the aid of successive Governments to dig them out of whatever hole they had dug themselves into; over 70s Medical Cards, the Swine Flu, the Vaccine fiasco with pharmacists, the North Dublin Co Op mess and more.

But our patience is coming to an end. The Minister and the Department need to know that they are in danger of killing the golden goose that is the GP service. They must come to their senses and do so quickly.

Turning to our Community Medicine and Public Health Doctors, we continue to focus on trying to have the moratorium on recruitment lifted as it is now significantly hampering the ability of these professionals to do their jobs in the manner required.

Thankfully last year there were a number of specialists in Public Health medicine appointed and we hope to continue that trend this year.

In respect of Public Health in particular, we continue to try to promote engagement with the HSE in relation to Transformation of the Population Health Directorate and the Public Health Emergency out of hours service.

In respect of AMOs we expect to be in a position to commence a
case with the Equality Tribunal in the near future – having tried and failed to negotiate with the HSE on this matter.

In respect of Community Health, the report on the review of Community Health is due for publication shortly and we will monitor developments very closely to ensure that our members interests are protected.

Consultants are at the very heart of our health service and without their skills and dedication the service could not function.

However here too we see the failure of the dead hands of the HSE and the Department of Health.

The level of crisis facing consultants was revealed last year when we published details of a benchmark study which highlighted the despair now felt by so many outstanding professionals up and down the country.

Perhaps this was best summed up in the revelation that one in four of our consultants are now considering leaving the public health system – and the fact that this arises not from disputes over pay but as a result of the complete breakdown of trust between consultants and the HSE.

A huge factor in this of course has been the relentless spinning and criticism against consultants which has been undertaken by the HSE over the past two years in relation to the public/private mix.

It is impossible to imagine any other sector where the administrators of the system have so systematically undermined the morale, the professionalism and the clinical independence of a group of people upon whom those administrators are utterly dependent.

It is nothing short of a disgrace.

Perhaps the most cynical example of this was in comments made recently by the departing Head of Human Resources at the HSE. His comments about the hours worked by consultants were made without any foundation or supporting evidence and only served to damage the good name and reputation of consultants.

The IMO absolutely rejects such assertions. Consultants already work beyond their contracted hours with many of them attending over weekends. Their commitment to the service and their patients is unquestionable and to attempt to undermine that work in the eyes of the public is both foolish and nave. And it will certainly do nothing to improve trust.

The HSE and Government would be more productive in addressing the barriers placed before Consultants in undertaking their day-to-day work. The goodwill shown by Consultants can only be offered on a long term basis when it is acknowledged and reciprocated by the employer.

It is a priority for Consultants that the Contract Implementation Group gets up and running. The failure to ensure the full implementation of the revised contract speaks volumes about the dysfunctional nature of the HSE which can’t even honour the agreements it negotiates.

This failure shames the HSE. But more importantly it fails the patients the HSE serves.

NCHDs dominated the agenda for a number of months last year and threaten to do so again in the coming months. When young doctors simply no longer want to work in the Irish health services because they fail to see a future here, you have a crisis and NCHDs simply don’t see the point in staying in this country.

The issues that are at the heart of this crisis are:

  • the failure of the HSE to ensure that the NCHD Contract is fully implemented
  • the failure of the Government to comply with the European Working Time Directive (EWTD);
  • the failure to provide sufficient structured training programmes leading to consultant posts

The NCHD Benchmark survey conducted on behalf of the IMO last year confirmed that the above issues are at the core of the reasons driving doctors to seek opportunities overseas. Ignoring the views and opinions of the very people who the Health Service will rely on for the delivery of future patient care is an act of recklessness.

Failing to entice your own graduates to stay with you in Ireland is bad enough. But the chaoitc mismanagement of the consequent recruitment programme organised by the HSE was simply shocking - a shameful mistreatment of doctors hired from abroad under pressure simply because the administrators had failed to plan properly for the exodus their own policies have provoked.

The mismanagement threatened to cause a real crisis in our hospitals and we would have been woefully underprepared to respond to one had it arisen.

The IMO is activly engaged on each of the three key areas I identifed a moment ago.

In respect of contracts, its simply not acceptable for the HSE to hold a dismissive attitude to NCHDs who they seem to regard as little more than workhorses for the hospital system.

It is not acceptable for them to simply state that hospitals have to remain within their alocated budgets as if this is justification for their failings and the breach of contractual and statutory rights of NCHDs.

In 2011we had some significant success in forcing hospitals to pay NCHDs what they are owed. We will continue to challenge each hospital which fails to pay NCHDs what they are entitled to.

In respect of the European Working Time Directive, the EU Commission has now put the Government on notice of what it regards as a serious infringment of this Directive and the Government is being extraordinarly tardy and misleading in its response.

We will not let them escape close scrutiney on this issue and we have sought a meeting with the EU Commission to explain to them the reality of the situation in Ireland – as a counterpoint to the spin they may have received on this matter from the Department.

I also mentioned the failures in respect of training for NCHDs and future career aspirations. At present a doctor has only a 25% chance of getting a consultant post when they have completed higher specialist training and this is forcing NCHDs to work abroad. Many, of course, are not inclined to return.

If the current crisis is not addressed as a matter of urgency the potential impact on the ability to fill Consultant posts in the future - with highly trained and motivated doctors – will be questionable.

There is an urgent need to organise and structure the Health Service in Ireland based on long term sustainable plans and not the current piecemeal, short-term and headline grabbing approach.

A stark reality is that Ireland has fewer consultants per head of population than many of our European neighbours and our NCHDs are leaving the system in ever increasing numbers.

As an Organisation we have called upon Government to develop a comprehensive capacity planning and retention policy for the health services. I again urge the Government to engage with us and other stakeholders in developing such a plan so that we can look forward to a health service adequately staffed by consultants and a proper career path for our medical graduates.

The Minister’s view is that the introduction of a new Specialist Grade will reduce the number of NCHDs moving overseas to continue their training and as a consequence assist in addressing the shortage of doctors in the Health Service. He seems to see this new grade as some sort of “silver bullet” which will also address the shortage of consultants.

However the Minister has resolutely failed to provide any detail of the new grade, how it would operate and how it will address the pressure points in the current system.

There has to be clarity on the purpose and value that this proposed new role would achieve. If this is a short term political stroke that does nothing for long term NCHD retention and career prospects and/or devalues the role of Consultants it is obvious that no significant long term benefit will accrue to patients.

What the Minister has missed in all the rhetoric is that the introduction of a new grade does not, and will not, address the retention crisis that the service is facing. Recruiting doctors from overseas and a new Specialist Grade does not tackle the fundamental problem of retention.

Finally – moving away from the priority areas for individual specialities – we will over the coming year continue to address a number of broader themes which are critical for doctors everywhere in this country.

Firstly, the need for greater respect in how doctors are viewed and dealt with by the HSE and the Department of Health and Children.

I’ve spoken on a number of occasions of the general lack of respect which seems to characterise the HSE and the Department in their dealings with us and with our individual members. Its an appalling reflection of an arrogance that poisons relationships and frustrates progress. We have always tried to be respectful of those we are dealing with – even when we fundamentally disagree with their positions – and we demand the same from those who deal with us.

Secondly – the growing trend of de-professionalising the health services also threatens the broader health services.

Our health services have been built on the bedrock of an unimpeachable professionalism amongst doctors. More recently there is a greater and greater tendency to talk of health care in financial and commercial terms as if it were simply another commercial activity and to apply commercial measures to it. This is a dangerous path and if we proceed too far we will risk much of what is so special about medicine and healthcare. We will fight to resist that.

Thirdly – we continue to worry about the danger of intrusive over regulation. The Health Information and Quality Authority is in danger of putting in place regulations that are impractical and counter-productive.

To close I’d like to thank a number of people.

Firstly – and most importantly – I want to thank all the members of the Organisation. The strength of this organisation comes from the support of all its members across the country and I am very grateful to all of them for their continued support in these difficult times.

I want to thank in particular those members who have served on Committees or as Officers of the organisation or as Trustees. Each of these roles requires a lot of time and energy and we very much appreciate the commitment which each of you have made to the organisation.

I want to thank my colleagues in Fitzwilliam Place who have worked incredibly hard throughout the year on representing our members, defending your interests and preparing for this AGM. I know that everyone appreciates all that you have done.

And finally I want to express my appreciation to outgoing President Dr. Ronan Boland and incoming President Dr. Paul McKeown.

I’ve worked very closely with Ronan this past year and I know the energy and time and dedication he invested in his term of office. The hours were long, the calls late at night or early in the morning were very frequent and the pressure was intense. Yet Ronan dealt with it all with great grace and enthusiasm. Thank you Ronan for all you have given to the organisation.

And I’m looking forward very much to working over the coming 12 months with Paul. Being elected President of a member organisation like this is a great honour Paul and I know that its one which you richly deserve. I know that you will bring great skill, insight and energy to the role.
Ladies and Gentlemen, I said at the outset that our role was to represent, defend and promote the interests of doctors across the country and to promote the development of a caring, efficient and effective national health service.

These are simple objectives to set out but they are incredibly difficult to fulfil – not least in the context of the wider crisis facing the country.

Nevertheless I want to stress again today that everybody in the IMO is 100% committed to doing all in our power to do so.

Go raibh mle maith agaibh.

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