Situation Vacant

The irony of life imitating art is not lost on Smyth and other community leaders in Feakle, who have recently mounted a rearguard action to prevent the loss of a medical service for the village — albeit without the mendacity of their Canadian counterparts.

The sad truth about Feakle is that the vacancy for a GP in the village was advertised twice by the Health Service Executive (HSE) over the summer, but the salary of €90,000 failed to attract a single application. Not even Smyth’s offer of a rent-free period to any new incumbent of the modern Follaine Medical Centre, which he owns, has enticed any prospective replacement GP. For now, patients, many of them elderly, must travel 10km to a medical centre in Scarriff to see a doctor.

The apparent lack of interest in the post has sparked alarm in the area, in what is seen as a harbinger of a problem that will affect many other rural communities in Ireland, as local GPs approach retirement age and newly qualified doctors hit the emigration trail. While locals have been prompted into action to save the surgery in Feakle, there is a recognition by a variety of stakeholders that the issue is one that needs to be addressed on a policy basis by the health authorities.

Comparatively, Feakle is surviving the recession better than many other places of a similar size. All three shops (one owned by Smyth) and four pubs in the village have withstood the threat of competition from supermarket multiples over the past decade — Feakle’s relative distance from the big towns of Ennis, Limerick and Gort probably helps the sustainability of such businesses. “There’s been a lot of investment, not that it’s readily obvious,” said Michael Collins, chairman of Feakle community council. He points out that it has a state-of-the-art school, modern water and sewerage systems, and broadband reception that is probably the envy of other parts of rural Ireland,as well as other amenities, including a large playground and community centre.

But signs of Feakle’s vulnerability are also visible. The local GAA team, which last won a senior county hurling title in 1988, is now playing at intermediate level and the club has been forced to merge with the neighbouring parish of Killanena- Flagmount. The local national school has lost one of its four teachers due to falling student numbers, even though the population for the electoral area of Feakle showed an increase of 31 to 367 in the 2011 census. There is little local employment following the ceasing of production at Finsa Forest Products in Scarriff in 2011, with most residents now commuting to jobs in Ennis, Shannon and Limerick.

AS ELSEWHERE, the residents of Feakle view the presence of a medical practice in the same terms as that of the post office, school, pub, grocery store, priest and number of GAA teams — a barometer of the village’s health and future.

For decades, the east Clare village — a stronghold of traditional music and the home town of Brian Merriman, author of Irish-language classic The Midnight Court, 19th-century healer Biddy Early and All-Ireland-winning hurling trainer Ger Loughnane — was served by a local GP, including the late Fianna Fail TD Dr Bill Loughnane. Following his death in 1982, the practice was run by Dr Gus Conlon until his retirement two years ago, at which point it was taken over by Dr Madeline Murphy who moved into the area. However, she informed her patients during the summer that she would not be returning to the practice following her return from annual holidays in July.

In a sign posted on the surgery’s door, she wrote: “Despite all efforts for 18 months, the practice has not grown and I can no longer sustain the financial burden of it remaining open.”

Murphy claimed that she had been involved in “hopeful negotiations”, but was notified on June 19 by the HSE that there was “no workable rescue plan”.

Although it is understood that Murphy grew the practice from 120 medical-card holders to 170 during her time in Feakle, it is still not at a level regarded as economically viable for GPs.

Dr Darach Ó Ciardha, chairman of communications at the Irish College of General Practitioners (ICGP), describes Feakle as an example of the “perfect storm” that is hitting rural practices due to declining populations, as well as substantial cuts in top-line payments to doctors and the discontinuation of rural-distance allowances.

“Under the current system, no allowance is made for the fact that a GP in an isolated rural area is required to cover a large but sparsely populated geographical area with all the associated pressures of travel, logistical difficulties and clinical responsibility, including out-of-office hours, but with low levels of practice income,” said Ó Ciardha.

He points out that capitation fees paid to doctors for treating general medical service (GMS) or medical card patients have been reduced on average by 38% cumulatively over recent budgets. According to the ICGP, the average capitation fee for a male patient aged 40 years or younger is about €140, rising to €300 for patients over 70. It estimates small rural practices such as Feakle’s might only generate a turnover of €19,000 per year, from which costs and overheads must also be deducted.

Ó Ciardha said there is a range of manpower issues facing the profession, not least the need for active succession planning, given that 12% of family doctors are within five years of reaching 70 — the age at which they are contractually obliged to cease providing services under the GMS scheme. It is fair to assume the vast majority of the 258 doctors currently aged 65-69 will retire in the next five years, but the ability on the part of the health authorities to replace them is less certain.

Worryingly, an ICGP survey of 649 trainee family doctors published last week showed that only a quarter expressed a commitment to staying in Ireland, while a similar proportion were undecided about where to base their career following 10 years of medical studies.

A survey of 445 newly qualified GPs who graduated between 2010 and 2013 revealed that almost 17% were already working overseas. Of these, fewer than a fifth were planning to return to Ireland to work. In addition, more than half of the graduate GPs currently in Ireland were not convinced they will stay here either.

On a more positive note, 60% of recent graduates expressed a preference to remain in Ireland. However, they pointed out that uncertainty around their professional roles, defined career progression opportunities and the role of GPs in the healthcare system remained issues of concern.

In a finding that will intensify fears about the future of small rural practices, fewer than 2% of graduates could see themselves running a surgery single-handed. “This raises questions as to whether there will be local centralisation of general practice services, as well as the impact on healthcare in remote communities,” said Ó Ciardha.

More generally, he believes family doctors face a period of unprecedented change due to the government’s controversial plan to introduce free GP care for children under the age of six, as well as universal health insurance in the longer term.

Following discussions with Feakle community council and local representatives, the HSE has decided to advertise the vacancy for a third time in the next fortnight, with a subtle but substantial change that has given locals grounds for cautious optimism. The HSE said it would, “in exceptional circumstances”, consider applications from doctors who already operate a GMS list. “We share the community’s wish to exhaust every avenue to have a GP presence in the area,” said Bernard Gloster, the HSE Mid-West area manager.

The move increases the possibility that one of the practices in neighbouring towns and villages will take over the running of the surgery in Feakle. Although not an ideal solution, it is a measure appreciated by community representatives.“Local HSE officials have gone beyond the call of duty. They could have shut the practice, which might have suited the HSE at a national level in terms of financing,” said Pat Hayes, a local Fianna Fail councillor.

However, Hayes, brother of renowned fiddler Martin Hayes, readily acknowledges that Feakle’s recent experience is symptomatic of what is happening in many rural towns and villages. “There is the danger of falling population because people won’t come to the area or stay here if you don’t have services like a doctor’s surgery,” he said.

“People are getting educated here and then emigrating, and it’s not just medical graduates. Yet we have to go to countries like the Philippines to recruit doctors and nurses to work in Ireland. We need a change in policy that encourages trainee and graduate doctors to stay.”

Jim Connolly, founder of Rural Resettlement Ireland, which he established in 1990 to reverse depopulation of the countryside by encouraging families to relocate from large urban centres, is even more frustrated at official efforts to halt rural decline. Also based in Co Clare, Connolly argues the level of depopulation in rural Ireland is even worse now than when he set up the organisation 24 years ago to put a brake on an earlier wave of emigration.“Recessions always hit rural populations worse than urban centres, but these things come in cycles and they will get better again. But that is no use if basic infrastructure like schools and surgeries are gone,” he said.

THE ICGP remains sceptical about the HSE’s attempt to find a replacement GP for Feakle, questioning whether merging practices is a real solution for the replacement of retiring medics in rural areas. The organisation believes the HSE needs to take more comprehensive, urgent action to reverse the erosion of country practices.

“Allowing practices from larger towns to amalgamate their GMS lists may plug a hole temporarily, but care is then delivered further away from the community in which patients live and this is ultimately not ideal for delivering high-quality general practice,” said Ó Ciardha. “It has been proven that well-resourced general practice saves lives and reduces the burden on already stretched health budgets.”

Back in Feakle, Smyth, whose family have run a variety of businesses in the village since 1952, including a hotel that shut its doors 15 years ago, has witnessed boom-bust cycles long enough to know that fortunes change, and he looks forward to handing the keys of the surgery over to a new tenant. “You have to be optimistic to survive in rural Ireland,” he said, smiling.