Have we a shortage of GPs?

[Purple]

As we have a shortage of GP's many are unable to accept new patients as their books are already full.

No, we have a very high number of GP's but a large proportion of them work part time. That's the problem; the State invests around a third of a million in training them and then they won't do a days work. Incidentally, we train more doctors per head of population than any other country in the world. A very large proportion of them are overseas students, sponsored by their country to train here, so when they graduate and complete their training they are obliged to go home. Therefore when you hear doctors saying that X% of doctors immigrate each year because they are badly paid here they are telling lies.

I believe it is annual capitation - currently €403 - higher if the patient is in a nursing home. There are also other general support fees for GP practices.

It's also worth noting that for every one Euro they get from the GMS ten percent on top of that it put into their pension. There are also considerable extra fees allowable, even for their medical card patients. A full time GP will earn €150k - €250k a year with a minimum of another €100k on top over the last 2 years due to Covid vaccines. That doesn't include their GMS pension. I wouldn't be too sorry for them.

 

[arbitron]

No, we have a very high number of GP's but a large proportion of them work part time. That's the problem; the State invests around a third of a million in training them and then they won't do a days work. Incidentally, we train more doctors per head of population than any other country in the world. A very large proportion of them are overseas students, sponsored by their country to train here, so when they graduate and complete their training they are obliged to go home. Therefore when you hear doctors saying that X% of doctors immigrate each year because they are badly paid here they are telling lies.

I don't know what sources you're drawing on for these claims but they are not accurate. If you're referring to HSE figures from 10+ years ago that were reported in the media as training costs, those were mainly salary costs. It takes 4 years to train a GP, so that's €75,000 a year on average based on your figure but 90% of that time is spent providing service in either a hospital or GP practice, i.e. seeing and treating patients. They have 1 protected half day a week where they are in lectures/tutorials, and then the other 4.5 days they are working. The contracts run for 6-12 months, rolling over the 4 years, so no permanency, and at the end of the training there is no guaranteed job.

It's also inaccurate to say that the issues around doctor numbers are due to international students going home after graduating. After medical school you must complete an intern year in order to get your full registration as a doctor. The vast majority of international graduates are non-EU, mainly from the Middle East and Asia. Without an EU passport, most of these graduates are not eligible to get an intern post in Ireland because there is a shortage of spots and all Irish/EU candidates are given offers first. This means that if a Malaysian medical student graduates top of her class in Trinity she will be ranked below the worst performing Irish guy who scraped a pass.

The rules around eligibility for postgraduate training were relaxed slightly this year but that won't be reflected in any numbers yet. Ultimately there is strong quantitative and qualitative evidence that we lose a lot of doctors abroad because of Irish working conditions. Of my dozen close friends from college, 9 are abroad and never coming back. 1 has come back for family reasons but has regretted it from day one when she was told she had no admin support, no desk to use, and no clinic room to see patients in. Have a read of Dr. Niamh Humphries excellent research, testimony before the Health Committee, etc. It's very clear what's happening. People seem very focused on pay but there is much more to it.

As for GPs going part time, I'm not a GP and would never do it. One day as a GP is like 2 days in another specialty, it is relentless.

 

[Purple]

I don't know what sources you're drawing on for these claims but they are not accurate.

The OECD

If you're referring to HSE figures from 10+ years ago that were reported in the media as training costs, those were mainly salary costs. It takes 4 years to train a GP, so that's €75,000 a year on average based on your figure but 90% of that time is spent providing service in either a hospital or GP practice, i.e. seeing and treating patients. They have 1 protected half day a week where they are in lectures/tutorials, and then the other 4.5 days they are working. The contracts run for 6-12 months, rolling over the 4 years, so no permanency, and at the end of the training there is no guaranteed job.

It takes 4 years to specialise as a GP after you qualify as a doctor. That's the cost I'm talking about. That first 6 years costs around a third of a million. Of course they are used as cheap labour by their older better paid colleagues in their last few years and during their 4 years of training. That said any qualified doctor can work in general practice.

It's also inaccurate to say that the issues around doctor numbers are due to international students going home after graduating.

Yes it is. International students make up 60% of the RCSI's student body. Most of them want to go home after graduation. They aren't leaving because of pay and conditions, they are going home. Saying otherwise is a lie. Irish doctors may well be leaving because their colleagues are so bad at organising and running the health service but that's their own fault, most hospitals are run by people who are qualified doctors and nurses so you only have yourselves to blame. I'm sure you're not suggesting that there is a lack of resources since we have one of the best funded healthcare systems ion the world and a young population. That's down to you guys being rubbish as running things and wasting money. Again, you've only got yourselves to blame there too.

After medical school you must complete an intern year in order to get your full registration as a doctor. The vast majority of international graduates are non-EU, mainly from the Middle East and Asia. Without an EU passport, most of these graduates are not eligible to get an intern post in Ireland because there is a shortage of spots and all Irish/EU candidates are given offers first. This means that if a Malaysian medical student graduates top of her class in Trinity she will be ranked below the worst performing Irish guy who scraped a pass.

Exactly. They go home.

The rules around eligibility for postgraduate training were relaxed slightly this year but that won't be reflected in any numbers yet.

Yes, the old boys and girls network is fraying around the edges. My friends father is from Iran. He couldn't get a consultant job here in 15 years of trying. He moved to London and was a consultant within 3 years. He just wasn't white enough for the job here. That was 20 years ago and I'm sure it's different now

Ultimately there is strong quantitative and qualitative evidence that we lose a lot of doctors abroad because of Irish working conditions. Of my dozen close friends from college, 9 are abroad and never coming back.

Yes, a badly run health service and high rates on income tax do drive people away but, again, when doctors quote total numbers of doctors leaving within a few years of graduating and don't quality it by saying that many are going home they are being deliberately untruthful.

1 has come back for family reasons but has regretted it from day one when she was told she had no admin support, no desk to use, and no clinic room to see patients in. Have a read of Dr. Niamh Humphries excellent research, testimony before the Health Committee, etc. It's very clear what's happening. People seem very focused on pay but there is much more to it.

Yep, the health service is very badly organised and run. Despite the massive budget they still manage to waste so much money that there's not enough for patient care but the people who work there don't care enough to fix it. I've very little time for people who have so little humility that they call themselves heroes, refer to themselves as working on the front line as if they are a soldier in a trench in the Somme and take no responsibility for the shambolic organisation that they are a major part of at every level.

As for GPs going part time, I'm not a GP and would never do it. One day as a GP is like 2 days in another specialty, it is relentless.

That's just nonsense. I've family members and friends who are doctors, some in Ireland and some in the UK. Some who have worked here and in the UK. Some who have worked as GP's and in Hospital medicine. None of them would pick A&E work or being on call every few days in a hospital over two three hour sessions a day telling people they have a chest infection etc for a couple of hundred grand a year.

 

[arbitron]

The above confuses many different numbers and conflates different arguments. It's going off topic now so I'm replying just once more for anyone else reading who is interested in the facts and the context.

Ireland's medical schools are full of international students and they bring in a lot of money for the state. Many/most international graduates from Irish medical schools go home after graduation. There are 2 main reasons for this. The primary one is that they just came to Ireland to get their degree and never intended to work here. That's fine, they pay huge fees and they subsidise the system, no-one is saying they must stay. These are not the numbers that are discussed when it comes to doctors leaving.

There is a 2nd group of international students who would like to stay here and work but they cannot because of employment rules. The barrier was a legal requirement based on interpretation of EU law, nothing to do with any doctors. In fact, doctors lobbied for the laws to be changed.

Irish graduates are a separate bunch. The vast majority of them can get an intern place. But after that we see the exodus, not just after intern year but all the way along the path to consultancy.

For Irish students, a medical degree is 5 years and costs the state around €11,000 per student per year. So the cost to the exchequer is €55,000 in total. For graduate-entry students, the government pays even less, as most of the cost is taken on by the students in the form of high personal loans. The cost for an international student to attend medical school here is around €300k and the government makes money on this.

Again, if we are talking about the 4 years of GP training, 90% of this involves delivering direct patient care in hospitals and GP practices. They are not students listening to lectures and sitting in libraries - they are Senior House Officers and Registrars working and treating patients. So any cost to the states is their wages.

That said any qualified doctor can work in general practice.

That is just not true. Vocational GP training has been a requirement for about 20 years and you must be on the GP specialist register to even be shortlisted for a job. You would not be able to see medical card patients and you would not even get indemnity insurance, not to mention legal and Medical Council requirements.

We cannot get enough non-consultant doctors, they are not available, so we are hiring people from all over the world, causing a huge brain drain and ethical quagmire that further disadvantages developing country health systems. And we still cannot get enough people.

Many health workers only stay because they have great colleagues who are working above and beyond to make things better for patients and for staff. In my experience the HSE is held together with good will and a lot of unpaid work.

None of them would pick A&E work or being on call every few days in a hospital over two three hour sessions a day telling people they have a chest infection etc for a couple of hundred grand a year.

That job sounds almost too good to be true but please share the details as I have a few hours free!

 

[Purple]

Ireland's medical schools are full of international students and they bring in a lot of money for the state. Many/most international graduates from Irish medical schools go home after graduation. There are 2 main reasons for this. The primary one is that they just came to Ireland to get their degree and never intended to work here. That's fine, they pay huge fees and they subsidise the system, no-one is saying they must stay.

Agreed.

These are not the numbers that are discussed when it comes to doctors leaving.

That's incorrect. They are included in the numbers quoted by the medical unions.

There is a 2nd group of international students who would like to stay here and work but they cannot because of employment rules. The barrier was a legal requirement based on interpretation of EU law, nothing to do with any doctors. In fact, doctors lobbied for the laws to be changed.

Really? Can you post a link to that?

Irish graduates are a separate bunch. The vast majority of them can get an intern place. But after that we see the exodus, not just after intern year but all the way along the path to consultancy.

Yes, they leave due to high taxes, a wish to travel and not liking the dysfunctional system that their fellow doctors play a large role in perpetuating.

For Irish students, a medical degree is 5 years and costs the state around €11,000 per student per year. So the cost to the exchequer is €55,000 in total.

Can you link to that? It costs around €7,500 to send a child to primary school. It it really only €3,500 more expensive to train a doctor? 10 years ago it cost between €31,000 and €45,000 a year. How have they managed to reduce the cost by 66-75%?

For graduate-entry students, the government pays even less, as most of the cost is taken on by the students in the form of high personal loans. The cost for an international student to attend medical school here is around €300k and the government makes money on this.

Yes, as I've said before, it's a great industry we have. My problem is doctors telling lies about graduates immigrating when they are actually just going home.

Again, if we are talking about the 4 years of GP training, 90% of this involves delivering direct patient care in hospitals and GP practices. They are not students listening to lectures and sitting in libraries - they are Senior House Officers and Registrars working and treating patients. So any cost to the states is their wages.

I agree, while they do consume teaching and other resources they certainly contribute. My point is about medical students, not specialisation training for graduates.

That is just not true. Vocational GP training has been a requirement for about 20 years and you must be on the GP specialist register to even be shortlisted for a job.

Nope, you need to have vocational training to have a Mediacl Card list but you can work for a vocationally trained GP as a locum without that specialised training. A patient could have a proctologist looking down instead of up and they wouldn't know any different.

You would not be able to see medical card patients and you would not even get indemnity insurance, not to mention legal and Medical Council requirements.

See above.

We cannot get enough non-consultant doctors, they are not available, so we are hiring people from all over the world, causing a huge brain drain and ethical quagmire that further disadvantages developing country health systems. And we still cannot get enough people.

We cannot get enough non-consultant doctors who are willing to work a full week, particularly in general practice but I agree; there is a global shortage of doctors and our high income tax rates are a disincentive to work for highly paid people.

Many health workers only stay because they have great colleagues who are working above and beyond to make things better for patients and for staff.

That's just hyperbole.

In my experience the HSE is held together with good will and a lot of unpaid work.

That's a terrible inditement of the people who work like that. It shows their inability and unwillingness to effect change and improve things. We should never treat well meaning incompetence as a virtue.

That job sounds almost too good to be true but please share the details as I have a few hours free!

General Practice. The average net GMS income in Dublin in 2018 was €170k a year (€210k before costs). Their private patient income is on top of that.

Their extremely generous GMS pension is not included in the above but as they get 10% extra contribution to their pension that means that the average GP got €21k in pension contributions from the State. Therefore their average package, net of costs, was €191k. Their income from their private practice was on top of that. It's safe to say that they are earning more than a quarter of a million Euro a year.

I'm not saying that they are over paid but they certainly aren't badly paid.

 

[NoRegretsCoyote]

You claim that:

For Irish students, a medical degree is 5 years and costs the state around €11,000 per student per year. So the cost to the exchequer is €55,000 in total.

But then go on to note that:

The cost for an international student to attend medical school here is around €300k

My understanding was that non-EU fees are there to recoup the full cost of provision, ie, something like €300k. So I don't think the Exchequer cost for an Irish medical student is as little as €55k, it's presumably a lot closer to the €300k.

You rightly note that there is a lot of brain drain of Irish medical graduates who've had a huge Exchequer subsidy to their education. I would tackle this by massively increasing fees.

Otherwise it is utterly daft that a medical degree has the same per annum cost as an arts degree. Cost of provision as well as career earnings are in completely different leagues.

 

[Early Riser]

My understanding was that non-EU fees are there to recoup the full cost of provision, ie, something like €300k

I don't know about the €300k total but non-EU fees are not run on a cost-neutral basis. They are run to be profitable and to subsidise other activities. The Indecon report from about 20 years ago estimated that the total annual cost (direct and indirect) for a domestic student in Trinity medical school was €13,259 but that the subsidy from foreign student fees reduced this to €8,981. The corresponding figures for UCD were €10,580 reduced by subsidy to €6,089.

 

[Groucho]

Ignoring all of the half-cocked explanations and miscellaneous blather, the simple answer to the OP's initial question is: yes we do!

And that shortage in more evident in some parts of the country than in others.

It is true that more females are qualifying as doctors and as GPs than males. And it is also true that a significant minority of them are choosing to leave the workforce for a few years or to work reduced hours. It's a worldwide problem, not unique to Ireland.

Here's the result of a recent Dutch study:

"Results: Female GPs worked significantly fewer hours than their male peers. GPs in their 50s worked the highest number of hours, followed by GPs age 60 and older. GPs younger than 40 worked the lowest number of hours. This relationship between working hours and age was not significantly different for women and men. As shown by path analysis, female GPs consistently worked fewer hours than their male counterparts, regardless of their age and employment position. The relationship between age and working hours was largely influenced by gender and employment position."

Age-related differences in working hours among male and female GPs: an SMS-based time use study - PubMed

The variation in working hours among GPs can be explained by the combination of gender, age, and employment position. Gender appears to be the most important predictor as the largest part of the variation in working hours is explained by a direct effect of this variable. It has previously been...

pubmed.ncbi.nlm.nih.gov

 

[Pinoy adventure]

Our local gp has a waiting list of at least 7 days so I would think the answer is yes.
A big shortage of them.

 

[NoRegretsCoyote]

The Indecon report from about 20 years ago estimated that the total annual cost (direct and indirect) for a domestic student in Trinity medical school was €13,259 but that the subsidy from foreign student fees reduced this to €8,981. The corresponding figures for UCD were €10,580 reduced by subsidy to €6,089.

That's interesting but there is a global market for medical school places. I doubt Ireland can charge non-EU students considerably above the cost of provision. RCSI manages to charge €57k a year.

If there are more recent estimates I'd love to see them.

 

[Early Riser]

That's interesting but there is a global market for medical school places. I doubt Ireland can charge non-EU students considerably above the cost of provision. RCSI manages to charge €57k a year.

If there are more recent estimates I'd love to see them.

I don't know about estimates but there are regular reports on universities relying on foreign student income to balance the books, eg,

The head of Cork Dental School, Christine McCreary, said as much as 50% of the class’s intake has to come from overseas, mainly Canada, Malaysia and Singapore, in order to ‘balance the books’ because otherwise they couldn’t afford the huge running costs.
Not only are Irish students missing out on places, but it is also contributing to the shortage of dentists here as most international students return home once they graduate......
......For this year’s intake, EU students doing undergraduate dental surgery at UCC will pay €9,630 while international students will be charged €46,000. At Trinity College Dublin fees for EU students are €9,339 and for international students are up to €49,500.

Irish students miss out on dental places due to reliance on overseas fees

It has been revealed that Irish leaving cert students are missing out on a place to study dentistry based on a flawed funding system.

rollercoaster.ie

 

[Purple]

That's interesting but there is a global market for medical school places. I doubt Ireland can charge non-EU students considerably above the cost of provision. RCSI manages to charge €57k a year.

If there are more recent estimates I'd love to see them.

I can’t see anything more recent that the link I posted and the information given by other posters. It certainly isn’t €11k a year though, as @arbitron erroneously claimed above, given that it was over €30k 11 years ago.

10 years ago it cost between €31,000 and €45,000 a year.

 

[Purple]

Ignoring all of the half-cocked explanations and miscellaneous blather, the simple answer to the OP's initial question is: yes we do!

So facts and data are “half-cocked explanations and miscellaneous blather”?
Well that attitude probably goes a long way to explaining why we can’t fix the problem.

And that shortage in more evident in some parts of the country than in others.

Yes, that’s the case with just about every problem.

It is true that more females are qualifying as doctors and as GPs than males. And it is also true that a significant minority of them are choosing to leave the workforce for a few years or to work reduced hours. It's a worldwide problem, not unique to Ireland.

Here's the result of a recent Dutch study:

"Results: Female GPs worked significantly fewer hours than their male peers. GPs in their 50s worked the highest number of hours, followed by GPs age 60 and older. GPs younger than 40 worked the lowest number of hours. This relationship between working hours and age was not significantly different for women and men. As shown by path analysis, female GPs consistently worked fewer hours than their male counterparts, regardless of their age and employment position. The relationship between age and working hours was largely influenced by gender and employment position."

Age-related differences in working hours among male and female GPs: an SMS-based time use study - PubMed

The variation in working hours among GPs can be explained by the combination of gender, age, and employment position. Gender appears to be the most important predictor as the largest part of the variation in working hours is explained by a direct effect of this variable. It has previously been...

pubmed.ncbi.nlm.nih.gov

See, you can do data too!
Should we have gender quotas in medicine? It’s clear that on a Marco scale it costs the people of Ireland more money to train one full time equivalent female doctor than a full time equivalent male doctor. How do we address that problem or do we just keep spending more of other peoples money training more and more doctors?
How about Student Loans or some other way which limits the frivolous waste or precious educational resources?

 

[Itchy]

I can’t see anything more recent that the link I posted and the information given by other posters. It certainly isn’t €11k a year though, as @arbitron erroneously claimed above, given that it was over €30k 11 years ago.

That is the vaguest source ever been used to support an argument! There is no context provided and there isn't even a by-line on the article.

 

[Towger]

Yes, there are several issues:
1. Population increase.
2. Changes in work life balance. Doctors now (as does everyone) want to work regular hours, therefore more are required to treat the same number of patients.
3. Large number of women becoming doctors, this feed back to work life balance. If people want to debate this I can introduce them to a recently retired surgeon who has a big issue over this.
4. The number of Irish students accepted for training is capped. I was told the ICGP control this number, but I cannot find proof. It is not a capacity issue as we train large numbers of overseas doctors. I know the overseas students cross subsidise, but the country is no longer (as) broke as when this practice started decades ago.

 

[Purple]

That is the vaguest source ever been used to support an argument! There is no context provided and there isn't even a by-line on the article.

Are you saying that it’s incorrect?
Interestingly the same article mentions that most graduates plan on leaving without qualification that most of that cohort are not from Ireland and are obliged to leave.

It costs €7-€8k a year to send a child to primary school. Do you think that a medical training will cost in the region of 50% more or is it more likely to be a multiple of that?

 

[Purple]

Good summation @Towger.
I’m of the opinion that those upon whom the State has lavished a considerable amount of it’s resources and who were lucky enough to be born with the privilege of intelligence* should be cognisant of those things and contribute to society accordingly.

Then again I’m a bit of a socialist.
If you’re religious then think of the parable of the talents Matthew 25:14–30


*if colour and gender are privileged when why not intellect?

 

[Early Riser]

. The number of Irish students accepted for training is capped. I was told the ICGP control this number, but I cannot find proof. It is not a capacity issue as we train large numbers of overseas doctors. I know the overseas students cross subsidise, but the country is no longer (as) broke as when this practice started decades ago.

"I was told" is not a reliable source. The ICGP has been advocating for increased training places and the number of places has increased from 159 in 2015 to 258 in 2022 and is projected to increase further. I understand that the restraint that they and the HSE have been working to overcome is getting suitable supervised training positions, particularly for the hospital-based element of the training, which is 2 years. ( See ICGP submission to the Joint Committee on Health : https://data.oireachtas.ie/ie/oirea...-college-of-general-practitioners-icgp_en.pdf)

Also, there was a Competition Authority report on GP services in 2010 and it did not identify any "cap" being imposed on training. It did note that there was an issue with prior hospital training (eg, in another speciality) that may have been undertaken by a doctor not being recognised for entrants to the 4-year GP training programme (https://www.ccpc.ie/business/wp-con...7/03/General-Medical-Practitioners-Report.pdf)

I know the overseas students cross subsidise, but the country is no longer (as) broke as when this practice started decades ago.

This seems to be conflating two different issues. The cross-subsidisation refers to the fees paid by non-EU medical students for their undergraduate training (not GP training). It relates to funding for University courses in general and in this case medical training specifically. I don't think this issue is any where near resolved. In fact it is probably worse now than decades ago. It has nothing to do with an ICGP (or similar) "cap" on training places - other than that more lucrative non-EU students probably impinges on overall capacity.

 

[Early Riser]

10 years ago it cost between €31,000 and €45,000 a year

Are you saying that it’s incorrect?

I would consider that source (an unreferenced and unquantified claim by a Fine Gael TD- or any TD) as unreliable.

The earlier Indecon Report indicates how difficult it is to drill down reliably into medical education costs per student. Also, that report indicated that 20-odd years ago the proportion of non-RCSI medical school funding that depended on non-EU student fees amounted to 53.3%. Of the rest 19.6% derived from the block HEA grant to the relevant Universities (the proportion of which relating to the medical school is estimated) and 26.5% from the HEA to cover individual medical student fees. I don't know how the proportion relating to non-EU student fees has changed in the interim. However, I take from this that these fees are well above the average cost of medical education, as they are a source of considerable subsidisation for the Colleges. Currently these fees range between €42,500 and €57,000.

I have been trying to make sense of a recent Dail reply on this topic but, as far I can make out, the current cost to the exchequer per undergraduate medical student amounts to about €18,700 - comprised of €3,600 from the overall block grant to the institutions, €5,900 individual student fee, and €9,177 additional ringfenced funding for medical schools. In addition, the students themselves are liable for the €3,000 Student Charge. Those eligible for grants will have this paid by the State also.
But I may have got it wrong: https://www.oireachtas.ie/en/debates/question/2021-11-09/510/

 

[Groucho]

So facts and data are “half-cocked explanations and miscellaneous blather”?

You opened this thread with a rhetorical question which you immediately proceeded to dissect with all the finesse of a lumberjack performing brain surgery. Hence, I would regard the above description of your subjective "facts" and poorly interpreted, half-baked "data" as being a tad charitable.

The overall tenor of your response has persuaded me not to engage further with you on this topic.