Dr Edel McGinnity
Dr Edel McGinnity, of Riverside Medical Centre, Mulhuddart Village, Mulhuddart, Dublin 15, spoke on Tonight with Vincent Browne last night about what it’s like being a GP in her area.
Dr McGinnity had given a presentation for the Irish Cancer Society about the chaos in the health service’s primary care and the inequality this represents for people from disadvantaged communities.
Edel McGinnity: “I’m a GP in northwest Dublin, in Mulhuddart. I’ve been there since 1995. I trained in Dublin, worked in Mozambique for a few years and then came to work in northwest Dublin.”
Vincent Browne: “What’s it like in Mozambique?”
McGinnity: “Well, it was very different, it was very interesting, it was a really stimulating place to work. It was the poorest country in the world at the time but it had a very, highly developed primary care system so I actually loved it there. It was very tough work, it had very high mortality there but I really liked working there.”
Browne: “Like, better than working where you work now?”
McGinnity: “No but, as I say, different. But I didn’t expect to find, that I would find the work just as challenging when I came back to Ireland. I had expected that it would be easier because Ireland is such a better off country.”
Browne: “Ok, how is it challenging?”
McGinnity: “Well, people who live in areas of most disadvantage in this country are three times more likely to die from cancer than people who live in the most affluent areas. They’re more likely to die from all causes, they’re twice as likely to die from all causes but they’re three times as likely to die from cancer. And they die younger and they get multiple illnesses at a much earlier age. So that’s been a difficult thing to deal with over the years.”
Browne: “Tell us about you practising medicine and what do you come across in relation to all that?”
McGinnity: “Well, for example, in my practice last year, in people under 65, where the mortality is more noticeably higher in these areas, there were 10 deaths in my practice last year, in people under 65, where you would expect the national average, now not the most affluent, but the average death rate you would expect between four and five deaths a year and in mine there were 10. So that reflects the part of northwest Dublin that I’m in, it actually has the highest cancer rate mortality in the country from a recent health-geo-infomatics study, from Maynooth….Inequality is the biggest predictor of early mortality.”
Later
McGinnity: “If you have a health service that’s distributed according to numbers, as opposed to need, then what you have is, for example in southeast Dublin, which is an affluent area – you have, we’ll say 1,000 patients. So you’ve got one GP, one public health nurse, one service, one physio, for those 1,000 patients.
But if you have the same service then, in northwest Dublin, one GP, one physio, one whatever service but you have twice as many people who are going to die within those 1,000 people. Twice as much sickness. So, in fact, you have twice as much sickness but you still have only the same number of health service provision, so you’re actually offering people half the service. And I’ll explain to you in a moment that, in north Dublin, there isn’t even one professional GP for 1,000 patients because the provision of GPs in northwest Dublin is so poor. So that’s a sort of double whammy.”
Browne: “And the reason for that is because of the extension of GP care to over-70s people and to people over-70s and people in the higher income, that GPs will look after the people who are better off and have medical cards, get paid more for looking after those people than they get paid for looking after people who are less rich?”
McGinnity: “Yes, that’s one factor. That’s definitely one factor.”
Browne: “It’s quite astonishing.”
McGinnity: “It is astonishing, yeah.”
Browne: “It’s led to a situation where GPs have migrated from the poorer areas into richer areas.”
McGinnity: “Yes and there’s a number of reasons why GPs won’t work in areas where I work – the work is complicated, there are more people, they are more sick, there’s a lot of risk involved, risk with mental health problems, with addiction, with child protection – it’s very stressful work. The medical card system is paid according only to age with no provision for need. So, whether a patient attends once, ten or 100 times, or no matter how complicated that visit is, the payment is still the same and because it’s age-related, in big parts of the peripheries of the major cities, where the populations are very young, the payment is actually 30% less than the average. So you have a lot of people who are much sicker and the payment is actually 30% less. So that’s why it’s impossible to get a GP. There’s one GP for 2,500 people in the greater north Dublin area. In northwest Dublin, it’s one GP for 3,500 people and the national average is one GP for 1,600. So in northwest Dublin you have half the GPs for people who are twice as likely to die and twice as sick. That’s the inverse care law.
Later
McGinnity: “We have a whole other type of Tiger mother out in Blanchardstown, just busy, out, hunting and foraging and protecting their kids and their families and they don’t put their own health needs first. So they don’t respond well to screening. Then, when they do have a GP, as I said, in parts of northwest Dublin, many of them don’t have access to a GP.
Even when they have a GP, it’s not so easy to actually do things like cancer screening and prevention because of the nature of the problems that these people come in with. So a typical patient in my practice, for example, I’ll call her Catherine. Fifty-three-year-old lady, comes in with, she has diabetes, she’s chronic lung disease, and she has eczema. Now that’s very typical of any patient, anywhere across the country. We don’t just do blood pressures like people think, we all manage chronic illness and complex illness, all the time. But what makes it different is that there are more of these patients, they’re younger, with their multiple illnesses and they’re really complicated by social problems.
So, in the case of Catherine, it’s that she has a 14-year-old who has behaviour problems. In the background, she’s still smoking, her diabetes isn’t controlled, and her smear has been overdue for a year. So before I call her in, my computer system tells me, this smear is overdue, you’ve got to do it. She’s missed her nurse’s appointment. So she comes in, she has a chest infection today and a flare-up of eczema and we start dealing with all of those. And then the phone rings, this is very typical of a day in my practice, the phone rings and you wouldn’t dream of answering the phone when a patient was with you but, in this case, it’s child protection social worker, these things crop up all the time and I have to take the call. So Catherine has to leave the room, I take the call, I make the notes, Catherine comes back in and then she tells me that her niece died three weeks ago and she’s really upset about that and she hasn’t been sleeping. She needs a letter for clothing which is really urgent and she needs it today. And her son has just been suspended from school. So she’s really worried about that. So we start into all of that and meanwhile, the waiting room is filling up, there’s more Catherines outside, waiting to get all these things done.
So we work our way through all that. We deal with the chest infection, the eczema, we look at her diabetes medications but, actually, she was eating very badly all around the time of her niece’s funeral so we postpone that until things are better. We talk about her sleep and the bereavement and all the other bereavements. We talk, at great length, about her son, and I undertake to do a letter later for the child psychiatry service and for the school. We make another appointment, we do the clothing letter because that has to be done right there and then. So we do all that and then we remember the smear and that we haven’t talked about her smoking. But I don’t feel like talking to her about her smoking today after her story about the bereavement. And I say to her, ‘we’ve got to do this smear’, ‘oh’, she says, ‘I’m just not in the humour, doctor’. And, you know what, I’m not in the humour for the smear either, after all that. And that’s how it is, these patients don’t get the care that they should have because they have two many acute health problems and acute social problems for us to be able to deal with all of that in the ten minutes that’s allocated to a GP consultation.”
Later
McGinnity: “The vast majority of GPs in this country are available every day for people so we are very accessible to people. We could reach the hard to reach but we’re too busy dealing with the day-to-day stuff to be able to do the really important work so, even if you do suspect cancer then, when you get a patient who..it’s really important to say that if you seriously think somebody has cancer, you get that patient seen. If I contact any of my hospital colleagues with a fax or a phonecall saying, ‘I think I’ve somebody here that has cnacer, they will be seen very quickly’. But there are 24 million consultations in general practice every year – you can’t send everybody for scans and tests and to the hospital. So if you’ve a patient who’s in that inbetween group where you’re this worried, but you’re not sure…say, for example, you had a middle-aged patient who has abdominal pain, out of the blue, a tiny bit of blood test changes in their liver for example and you’d really like an ultrasound, it could be something simple. It could be gallstones, it could be just fatty liver, it could be nothing at all but it could be pancreative cancer, it could be ovarian cancer in a woman. So an ultrasound is really helpful.
My patients in northwest Dublin wait an average 11 months for an ultrasound. If you live in southeast Dublin, and you have a medical card, you can have an ultrasound in eight weeks and, if you have health insurance, you will have an ultrasound tomorrow. Or, if you can pay, you can have it tomorrow…
The inequality within the public system. I mean, if you have private health insurance, that’s another level of inequality but even within the public system there are huge differences. So my part of the city, where people have the highest death rate from cancer, have the least access to healthcare. Colonoscopies are another example of a service that is really good for diagnosing colon cancer – the second most common cancer in this country. I had a patient last November who presented, again with not a definite worry – you know it wasn’t the so-called red flag, didn’t have weight loss, didn’t have bleeding but he had a change in bowel habits and, you know, essentially, I needed to know well why is this happening. I’d like him to have a colonoscopy. He waited seven months for that colonoscopy publically. And if he had been a public patient in South East Dublin, it would have been done in three months.”
Browne: “If he was a private patient?”
McGinnity: “If he was a private patient,”
Browne: “Or a public patient…”
McGinnity: “Yes, a public patient. If he’d been a private patient, he’d have had it in two weeks. So, you know, so that’s the kind of barriers you’re up against when you work in these areas. And, finally, and even when people do get into the hospital system, that’s not so easy either because they’re notoriously unreliable. Patients, we’re accused of having them where they don’t, where there’s been disappointments. And, you know, the hospitals then, it’s kind of one strike and you’re out now. If you miss one appointment you’re out, you’re back to the bottom of the list.
And I mean the reason people miss appointments…it’s obviously very frustrating for the hospital but the hospitals are rigid, they’re set up to suit themselves, they don’t make any provision for the kind of complications that people have in their lives, like I mentioned about the screening, moving house, there’s a huge flux in housing in the area that I work in or phone numbers changing or simply the vicissitudes of life. I mean, in the area that I’m in, a couple of weeks back, three young men died in the space of a week. And the whole community was devastated, you know, so people were too busy going to funerals that week to keep appointments. Now, in our practice, we have a system for that where, if we know they have an appointment – which we don’t always know, because the hospitals don’t always tell us – we will take the time to phone them and text them about those appointments to remind them because it’s coming from us ,and they trust their GP, they’ll often respond to that and go but that’s very time consuming for us.”
Browne: “So what can be done?”
McGinnity: “Well the most important thing that can be done is to allocate resources according to need and not according to numbers. There are, you know, we know there’s no money – that has been repeatedly stated, although there is money for bridges and road and stuff, whatever about that. But even within the health service, where there’s no money, I would challenge where the money goes. For example, the new proposals to give free GP care to under sixes. I mean it sounds good, it sounds equitable and universal and all children of the country will be treated equally but actually that’s a direct aggravation of this inverse care law. While there are patients getting half a service, people with the highest mortality are getting half a health service and yet money is being targeted at the healthiest people in the country, under sixes with, you know, higher incomes. There are examples of targeting resources where they’re needed. My practice is involved in a methadone protocol which is a special system where resourcing care for drug users who have the highest mortality of anybody under 65 and it’s a fantastic scheme that has made a huge difference to patients and all their families so I would, that would be the biggest thing, to direct resources to where they’re needed most, to where the people are sickest and most likely to die.”
Watch back in full here
I have huge sympathy for people who have limited access to healthcare.
At the same time, my sympathy is somewhat limited when it turns out that a lot of their problems are (apparently) caused by them refusing care that is offered, and wasting capacity by not showing up for appointments. I know you can’t turn your back on some people because others are causing problems, and I don’t know what the solution is, but my reading of this was that a lot of the problems in the areas she’s talking about are self-inflicted by the communities themselves (and obviously there are those in the community who are blameless as well).
If you can’t make an appointment you call (as far ahead as possible) and tell them that you won’t be there. Have a death in the family? I know this sounds uncharitable – but take five minutes and clear your schedule for the week! Or the month. Whatever you need – hopefully everyone will be understanding and facilitate re-scheduling, but your responsibilities don’t just disappear when you’re bereaved.
You’re right, it does sound uncharitable. And horrible.
Yup, it’s the ” I’m in mourning (or something really bad happened), stop the world! ” mentality.
That said, fair play to that GP lady for working through with difficult patients and raising the concern and describing it so well. She doesn’t really make excuses for the patient in her description, she’s quite even handed, maybe a bit too even – we’re all responsible for our own health and if you don’t take the advise of a good doctor, good fupping riddance to you, if you don’t care yourself, why should the doctor in fairness.
Again, fair play to this Dr
Or the “oh, I do not know how to process this at all and still be a functioning person, how do I even get up today, let alone call someone and talk to them about something so trivial as an appointment when my entire world has completely changed for ever and I don’t know how to cope or keep it together”.
I mean really, have a bit of empathy.
Yes Don, there are those that’ll play up any drama. If you’ve never met the type, that’s quite amazing. You’re extremely lucky.
I in no way suggest everyone is like that, but there are plenty who are, and this Catherine lady sounds like one.
See also DoM’s comment at 12.47 below.
Playing up the drama? Or dealing with a lot of sh** on her plate? I sense the latter, which is exactly the point the Dr makes
” these patients don’t get the care that they should have because they have t(w)oo many acute health problems and acute social problems for us to be able to deal with all of that in the ten minutes that’s allocated to a GP consultation.””
And see my reply to DoM. Do you really think that someone would be up for a smear after talking about the death of a close family member? Can you not see how that would be the last thing they are worried about? Life is messy and health interventions only do good when they are timed to fit around these. Anything else is a waste of time and money.
Really Clampers, playing up the drama? My sense was that this woman was overwhelmed and trying to cope as best she could.
You sense the latter, fine. In the example given, I don’t.
For the individual in the example….. “her smear has been overdue for a year”, we all have sh*t on our plates, some are better at dealing with it, this lady apparently is not.
I don’t know anyone who was ever in the humour to go to a doctor for anything.
Not in the humour me eye, she’s a year late and missed her appointment with the nurse, so this is the second appointment missed…. maybe she’ll get around to it next year.
Yes, because that is what the Dr said. That is how I sense it.
As I said below, screening is difficult. Lots of people don’t take it up for a range of reasons ie understanding personal risk and embarrassment, not wanting to know the result, having friends who had positives and quite invasive surgery (think lasers and genitals). Its not just a matter of having time, although that can be a factor as well especially if you are working shift work, or in low-paid, insecure work or just have an idiot for a boss.
And did you miss the bit where she had just been talking about her dead niece? Do you want a speculum in your cervix now? No, oh ok, thats understandable.
FFS
“understanding personal risk and embarrassment, not wanting to know the result, having friends who had positives and quite invasive surgery” – Now that is exactly the type of irresponsibility to ones own health I am talking about.
She’s obviously been speaking with her doctor for over a year about it, so there is no ’embarressment’ of any great heights.
‘not wanting to know the result’ – then stop wasting the doctors time.
‘having friends who had positives and quite invasive surgery’ – imagined pain, exaggerated by stories instills fear. Fear that’ll continue to grow with more delays. More nonsense. Every case is different. Do it now.
….so most of that excuse above is wishy-washy. This visit, the second missed appointment, is adding to the stress too and making it more difficult for herself ya know.
It’s a situation the patient is creating themselves, and she’s probably not aware that that is what she is in effect doing. She has stress upon stress piling up, she has an opportunity to get one off her back, and she postpones it… bad move on so many levels. Delaying an inevitable test because you are stressed is only going to cause more stress.
On the dead niece bit, dead three weeks prior… she should be strong for her brother or sister who lost a child. Call me harsh, mean, callous or whatever for that if you wish…. neither of us know the full story…. and without it, I say it’s “three weeks” since the death, of course share this with your doctor, but don’t use it as an excuse to add further to your own stress and thereby leave yourself even less capable of coping…. time to pull your socks up.
Its ok Clampers, you just dont get it. I see that.
“time to pull your socks up”
Wow. Nice one
I wouldn’t call you harsh, mean or callous Clampers but it sounds as if you’ve never had anything especially traumatic befall you. Three weeks is nothing. People fall apart, life is put on hold. You don’t know until it happens to you, and with a bit of luck, it never will.
Trauma….. moi… sorry now, but that kind of thing has befallen me in truckloads Buzz. I pulled myself up and out of it, with help.
And BECAUSE I didn’t put off getting the help, I’m the better for it. And so would this lady be if she did the same.
Our over-reliance on doctors is a cop out. There’s a lot we can do if we take responisbility for our own well being by eating well, trying to figure out ourselves what is wrong instead of rushing to the GP for antibiotics etc and handing over our care to someone else in a childlike way. But it’s true some people have extremely stressful lives and let their health take a back seat. The situation as described by Dr McGinnity is a symptom of greater social dysfunction.
Some people have the ability to take responsibility. For others, this is not the case for a variety of reasons from individual characteristics to structural pressures.
Yes, I agree but it should be put out there as an option, at school stage maybe instead of getting kids to memorise the names of rivers.
True. Knowledge is always a good thing but wont help you if you can’t afford the bus fare to get to the doctor or the hospital or the time off work to go to appointments.
Knowledge is always a good thing and is generally the thing that makes sure you can afford the bus fare.
@ rotide – smug as ever.
Don’t let me stop you mounting a facebook protest.
Says he, assuming everyone is on Facebook.
2cool4facebook
Wrong again rotide. But you should be used to that by now.
This is true.
And there are those that are just too lazy and need to be spoon fed on everything.
Discerning one from the other is a difficult task for the doctor.
Like who? I don’t know anyone like that. People are really not that stupid.
When someone offers you a potentially life saving screening, which will take place right then and there, and you say no…
To me, that does seem pretty stupid.
@ DoM You’ve obviously never had a smear test! I can see how a person just wouldn’t be in the humour.
To you maybe. But your concept of risk is maybe different to theirs. And for smears and breast screening, a lot of failing to uptake services in about embarrassment as well as not understanding risk. People are complex things so you need to find out why they don’t have screening rather than just say, oh they need to cop on, because that isn’t helpful and won’t increase screening uptake.
@Buzz – it is weird alright
So… they don’t exist now, because you don’t know anyone like that? OK.
No, because what I see tells me otherwise. You don’t have to believe that, and I don’t suspect you will.
Fair enough Don, I have seen it.
@Buzz 12:53pm
No, I haven’t had a smear test. That doesn’t mean that I’m incapable of weighing up a) my short term discomfort vs b) my long term health (especially if I missed it a year back), and making a sensible decision.
It’s absolutely the case that some people (maybe many, or even most) who are “under privileged”, or whatever euphemism you prefer, have just been dealt a shitty hand. At the same time, if you make bad decisions (and that’s not even a complicated one!) it’s eventually, inevitably, going to cost you.
How can anyone act surprised that people are dying of cancer if those same people are refusing to partake in screening programs??
Oh, fer Chrissakes. A smear test only takes a few seconds. It’s not pleasant but it’s not an operation or anything. The reason people put it off is mostly because they’re afraid of the result, I’d say, not the actual test.
I find, as I get older, that I have less time for people who don’t cope well with life (and I’m not including people with depression or medical issues). I refer to people who abdicate responsibility and play the victim card. Everyone has a hard life. Get on with it.
So now so. Rant over.
“Everyone has a hard life.” Lol, so wise! At what age did you work that one out? However, a smear test can take a lot longer than a few seconds and can be quite painful depending on the expertise or lack of on the part of the person doing it, and their choice of instrument ie, if they chose the wrong size speculum.
Read my posts daily: I’m full of wise sh*t like this.
Jaysus. Any smear tests I’ve had have been wham bam is it over already? Then again, I’m very ROOMY.
When I look around me lately, people everywhere seem to be barely keeping chaos at bay, irrespective of socioeconomic background. Is it Ireland or is it just life?
Probably related to expectations, I suspect. Whether it’s just Ireland or completely universal I don’t know.
It would be entirely possible to live a perfectly comfortable life, by the standards of any time pre-20th century, on nothing more than the dole. But when you start looking for all the things we mostly take for granted it gets more difficult. We strive to get the things we think we need, or deserve, or whatever, and overstretch ourselves. We put pressure on ourselves to reach beyond the bracket we can comfortably sustain.
In some ways striving for betterment is a good thing. I guess it’s when you overstretch, temporarily attain what you’re after, and then regress – that’s when it takes on the more negative, barely coping, total chaos feeling.
But then, what the fupp do I know?? I’m one of those f****rs who was born on third base and needs frequent reminding that I didn’t actually hit that triple myself.
So you’re one of those rare creatures with a prosperous, well ordered life with meaningful relationships and the sense of a benevolent universe, as opposed to one who wakes up frequently thinking what fresh hell awaits me?
Some days are good, I guess.
Same as the rest of us so :)
Who are you lot to be so judgemental. Hope it’s always so rosy for ye!
While we’re being judgemental, I hate the expression ‘it’ll be graaand’.