Stand-off on free GP care

Posted in Articles, Blog by saraburke on March 7, 2014

Doctors move to ensure the Minister’s primary care ‘Trojan horse’ falls at the first fence, see here my column from the Medical Independent from 6 March 2014

The Department of Health took the ballistic missile option by issuing its draft GP contract for under-six year olds with a super speedy 21-day consultation period (closing on 21 February). The move can be categorised as nuclear because the draft contract is totally different from the current contract. It is a detailed 40-page document with a strong emphasis on public health, prevention and the management of chronic diseases. Much of its content should be in any GP contract, except for an insane gagging clause, but presumably that’s why it’s a draft – so it can be negotiated down.

Within ten days, the IMO GP committee took the counter-ballistic missile route by threatening to injunct the draft contract if it was not withdrawn. Its main objection being that the draft contract is a “Trojan horse” for completely altering how GP care is provided and paid for. The IMO is right, it does.

At time of writing, the stand-off remains.

Free GP care for all is one of this Government’s big promises. So far it has failed to deliver its commitments to give free GP care to people on the Long Term Illness Scheme by March 2012 and to those on the High Tech Drug Scheme by March 2013. The reason given for not delivering was that extending GP visit cards to people with certain conditions was too complicated legislatively (although it refuses to show the legal advice on this).

Instead, under Minister of State for Primary Care Alex White, Government proposed delivering free GP care for under-six year olds in 2014 and extending it to the whole population by 2016. Notably, there is still no clarity on how it will be extended from under sixes to the whole population.

Giving everybody ‘free GP care’ will result in extra GP visits, which will require more GPs and changing roles; much work currently done by GPs could be done by others, such as practice nurses. The required work force changes were well documented in the 2009 Economic and Social Research Institute demographic projections for health service utilisation and the 2010 Report by the Expert Group on Resource Allocation.

GP care without charge is a good thing. We know the €40 to €60 fees paid out-of-pocket by 57 per cent of the population without ‘free’ access to GPs discourages some people, who need care, from getting it. It particularly hinders those without medical cards on low income or with chronic diseases in accessing GP care.

‘Free’ GP care is also an essential component of effectively shifting care from hospitals into the community. Obviously all sorts of other additional resources, such as access to diagnostics and other allied health professionals, will also be needed to make this happen. But providing access to GP care without charge is a critical step on the way to having a more sustainable and affordable health system.

International experience shows that when GP care without charge is extended to the whole population, there is a bounce, in that more people go to the GP, but this settles down quickly after its introduction.

Currently, 143,000 under sixes have medical cards and visit their GP on average 3.2 times per year. Given that those under sixes not covered tend to be from higher socio-economic groups, it is projected there will be an extra 3.1 visits per year for this cohort, requiring about 250 extra visits per year for each of the 2,700 GPs, or 430 extra annual visits for each of the 1,600 GP practices. It is estimated this will cost €33 million based on €50 per visit.

These figures are backed up by GP visit rates in Growing Up in Ireland, the most comprehensive health data on Irish children. Extending free GP visits to everybody else is expected to cost about €350 million.

The IMO figures differ hugely and are based on all visits to six GP practices over a year. This study finds an average consultation rate of 5.17 visits per year. The IMO extrapolates from these findings that if all adult private patients had the same number of visits as those with GP visit cards, there would be an extra 4.4 million visits per year. What the IMO figures do not show is predictions for under-18 and under-six year olds. Nor do they seem to take account of the fact that the oldest and the sickest already have free GP access.

Negotiating a new GP contract is one thing, extending free GP care to under sixes is another. There are political, social and economic imperatives to do both.

Doing both at the same time is not the best course of action. It will be interesting to see if and how these nuclear missiles from both sides can be intercepted and disarmed.

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