Minister for Primary Care Alex White has said he wants to improve the 'bad atmosphere' that currently exists between the Government/HSE and GPs, especially in the wake of the row over proposals to introduce free GP care for the under sixes later this year.
He says a way can can be found around the stumbling block that exists over the Government insisting that it cannot directly negotiate on GP fees, and says the draft GP contract for the scheme, which has been rejected by GP representative bodies, can be changed.
Alex White also admits that recent reviews of medical card eligibility may have initially been handled insensitively, but he stressed that these reviews were necessary. He believes people should not have to undergo means-testing for free access to their GP, as was the case at present, and the Government wanted to change this by having universal access to GP care free at the point of delivery by 2015.
In an interview with irishhealth.com, the junior health minister said the Government was anxious to reach agreement with GPs, as it could not run primary care without their cooperation.
"Admittedly, we have not had a good atmosphere recently between the Government/HSE and GPs."
"We need to address that. I intend doing so. I want to talk to the representative bodies. The Government cannot run primary care without the cooperation of GPs. I don't want GPs coming to work every day on sufferance or in a context where they feel they are not valued or listened to. I am very anxious to address that."
Asked how he intended to progress the under sixes scheme when the main GP organisations- the Irish College of GPs and the IMO - have effectively rejected the entire draft contract for the scheme, Minister White said he was not operating on the basis that GPs had rejected completely all of the contract proposals made on January 31.
"I think GPs have very serious concerns and they have expressed them to me in submissions on the contract. And you might even describe some of their concerns as fairly fundamental."
"I think there are some big issues that have come up in their submissions that can be addressed. They all say that they are in favour of universal access to GP services without fees. Speaking as a lawyer, and I didn't write the document myself, contracts of whatever kind have a tendency to be cold and black and white in terms of their content."
"I do appreciate what GPs say about resource issues needing to be addressed, how to deliver this service. Capacity in the system has to be addressed. The professional independence of doctors and their right to advocate on behalf of their patients has to be addressed. All of these things have to be addressed. I would expect, frankly, for there to be quite a few changes to the draft that I furnished to them."
Minister White admitted that the draft contact was an opening proposal but it contained many important aspects of what needed to be in a contract, in terms of preventive health and other items.
But surely the fact that GPs cannot negotiate directly with the Government on fee levels a major stumbling block?
"I am not naïve enough to think that fees are not important. We can negotiate on the content of the contract, and its scope. We can negotiate on pretty much everything that is in the draft contract- the only thing we have to make clear is that the ultimate setting of the fee is a matter for the Minister for Health. Even on the fees, the doctors and their representative body can have a meaningful input without running foul of the Competition Authority. I want to get down to negotiations with the IMO."
But presumably fees cannot be negotiated under current competition law?
"They cannot negotiate the fee in the following sense - where for example, they say 'we will not do this for less than x amount.' But with goodwill and with ingenuity, we can put together a really good contract that GPs can support and believe in and operate and we can have their input into the fees issue as well."
"We have to reassure GPs that they are really at the heart of this project and we can't do it without them."
Alex White accepts that the FEMPI GP fee cuts have had a real effect on their incomes, and by extension on their practices.
"Incomes in the public service right across the board have been cut and FEMPI have largely reflected the nature and extent of the public service income cuts as a whole. I would certainly believe and expect that we have now come to the end of the FEMPI cuts on general practice and we can now look to the future in a more positive way."
"I believe GPs are still comparatively well-paid and they should be. People have an expectation to earn a decent income as a professional person. The medical card scheme earnings published are often represented as high GP earnings, but in fact they are practice related and do not represent personalised income."
Is the money there to properly resource general practice and primary care to take on a wider workload and move care away from the acute hospital sector?
"There is not enough there at the moment. We must remember we are only just coming out of an economic crisis. Expenditure generally on health in our system, while it has been high in the past, has often been misdirected and I think it has to be redirected towards primary care. I think it is essential that we address chronic illness (eg diabetes) through primary care because there is no health system in the world that is going to be able to address it through the hospital model."
"But certainly, we need more resources to be put into primary care. We also need to move resources into primary care from other areas of the health system and we need we need to continue to make that case. I think the improvement, modest though it is, in the economic situation, will mean that we will be likely to be more successful in making that case in the short and medium term. The transfer of funding from hospitals to primary care will be a challenge, but I think universal access to GP services without fees is one major milestone along the way to moving more care to the community-to GPs and primary care."
"I would like to see the development of primary care as a dividend of the economic recovery. We would love to reduce taxes if we could but I would just as much like us to see us devoting resources to primary care."
Minister White says the politics of healthcare can't simply be about 'save our hospital'. It should be about funding and enhancing primary care. "I wouldn't mind seeing people out on the street advocating for that."
He indicated he had not ruled out the introduction of co-payment by patients as part of the universal GP care scheme due to be launched in 2016.
However, he has stressed that co-payment, under which patients make a contribution to the cost of a GP visit, would not be part of the free GP care scheme for under sixes. This scheme is due to be introduced this year, although the Minister is at loggerheads with the GP organisations over the proposed contract for the scheme.
Asked if some patients would have to make a contribution towards their care under the 'free' GP scheme for the entire population in 2016, Minister White said he was not putting forward definite proposals for a co-payment system.
"However, I understand the case that is made for a modest co-payment. But there will be no co-payment and no charge, nominal or otherwise, for the under sixes scheme."
The junior health minister said he was currently developing a paper for Government on how the full GP scheme for the entire population can be rolled out.
He said arguments for funding systems such as co-payment could be made in that context.
Minister White said the timeline for the introduction of the under sixes scheme was still the middle of this year and it was planned to introduce the universal GP scheme by 2016.
He admits that universal access to GP care for the entire population, which is due to be introduced in 2016, will only provide GP services, not the other ancillary services that current medical card holders can avail of.
"The universal access is to GP services without fees, that is what we have agreement on to deliver. I accept that access to your GP alone is not enough to cover all of your health needs and we just have to ensure that first of all the existing medical card system will be there so that people on lower incomes who are covered by medical cards will continue to have access to all of those services."
He said free access for all to other services, for example, physiotherapy, psychotherapy, would eventually be covered under UHI. "But I would love to see us trying to make progress on that even before UHI. We don't have the resources at present to deliver the full level of access to services currently available under the full GMS card."
Asked if he agreed that cuts to medical cards had been poorly handled by the Government and HSE, Alex White admits some of the language in the letters sent out to patients was 'a bit blunt'.
"I think that is a criticism we can take on board and we did try to change that. If on the other hand people are saying that we shouldn't carry out reviews of eligibility, I'm afraid I have to honestly say, with as much sensitivity as possible as a Minister and as a TD who is in touch with people every day of the week, that there isn't really an easy way to conduct a review of somebody's eligibility."
"You can write out to them, invite them to give information about their financial situation, give them time to do it, give them more time if they need it, give them assistance with it. Maybe we were a little bit slow at the outset in emphasising that we would be prepared to do that. I think we didn't reach out to people as well as we could have at the outset. But I'm not going to say that we shouldn't have reviews of eligibility."
Would he not accept that some people had their medical cards wrongly downgraded or taken away?
"You have to remember the scheme is based on financial means. If people lost eligibility it means they were not eligible for a medical card on the basis of their means for the card that they had. I accept it is awful to remove any eligibility from anybody, no-one likes doing it. The tragedy of our system is that it is means-tested - we should have a universal system, and this is what is planned. We shouldn't have to have people engaging in means-testing for access to their GP."
Minister White admitted that the the level of primary care centres currently being provided is well short of the number envisaged in the Primary Care Strategy of 2001.
He said the economic downturn would have had an effect on the process as some of the projects were dependent on developer investment and availability of funds.
"I think what was outlined in the Primary Care Strategy in terms of a network of primary care teams and centres will come to fruition and I certainly hope and intend that it will."
"Between March 2011 and February 2014 when the Government came in, 35 centres across the three methods- HSE own build, operational lease and PPPs, have come on stream."
We are looking at an additional 20 opening between 2014 and the first quarter of 2015, 16 of these are operational lease and four by direct build, and we are looking at a further 11 expected to be delivered by direct/own build from 2015 to 2016.
"We have 16 locations identified as being suitable for private-public partnerships (PPPs). We have lodged 15 planning applications and the other one is about to be lodged."
He said there was likely to be a further tranche of PPP-funded primary care centre developments approved at Government level.
On primary care teams (PCTs), where GPs and other healthcare staff work together to provide a wide range of treatment services in the community, Minister White admits this plan hasn't universally 'caught on'.
"There are a lot of good examples where they are working effectively around the country. They need to be supported and I intend supporting them as best I can."
The Minister said that as of December last there were 419 PCTs in place, and a further 48 teams holding multidisciplinary meetings but not including GPs.
"Admittedly, there is a need to look at the whole PCT concept. Doctors are not that keen to be going to meetings all the time. This over-emphasis on meetings might need to be addressed. I would hope that the context that we now have for further discussions on the under sixes proposal and on the broader development of a new contract will give us a better context for discussing this type of issue than we have had recently."
"GPs often say to me they don't want to be spending all their day at PCT meetings. This over-emphasis on meetings might need to be addressed. Professional people can collaborate in a centre or on a team without sitting down to formal meetings."
Minister White was heckled when he addressed a conference in Clonmel at the weekend organised by the Irish College of General Practitioners.
Discussions on this topic are now closed.