Government should get real with GPs

  • Niall Hunter, Editor

Aneurin Bevan, the Labour Party health minister in the 1940s who oversaw the creation of the National Health Service, said he overcame the opposition of doctors to the new system by 'stuffing their mouths with gold'.

This was at a time, it should be said, of national penury in the post-World War Two UK economy.

One could hardly accuse James Reilly of the same profligacy in his attempts to introduce free GP care for all children under six, and eventually, free GP care for everyone.

GPs have been vociferous in their opposition to the plans put forward by the ex-GP health minister.

Not so much to the concept of free GP care at the point of access per se, (although you suspect deep down there is an innate resistance to 'socialised medicine' among some GPs) but to the methods employed by the Government to introduce free care.

GP organisations in recent months have been engaged in a campaign of opposition to the proposals for the new scheme

Along the way they have cited how recent major fee cuts and a recession-driven drop in private practice income have decimated their practices, which are in essence, small businesses.

On top of all this woe, they say the Government is now trying to railroad them into a new system which will, they claim, lead to a heavier workload which will overwhelm their already under-pressure practices.

This extra work, they claim will be expected to be done for little or no increase in real income, against a background of a not-so hidden Government agenda to exert control over GPs, most of whom are independent contractors who do a good deal of work for the State through the medical card scheme.

Now, under normal circumstances, and in view of the still fairly shaky state of the country's finances, many of us might dismiss much of the GPs' complaints as yet more special interest pleading by a relatively well-heeled group. Not much different perhaps, to the teachers' current opposition to the junior cycle proposals.

And GPs' experiences are not much different to the financial plight suffered by many small businesses throughout the economy in recent years.

All poverty is relative, and the level of financial suffering endured by professionals and ordinary workers during the recession has been to some extent varied and nuanced. There is little doubt, however, that many GPs have taken a big hit, and feel they are now being asked to take on extra work for what could be very minimal fee rates.

When one looks at the tactics of the Government to date in attempting to introduce free GP care, any reasonable person would have to conclude that the GPs in this case are are justified in their frustration and anger with the Government.

The current Government, when elected in 2011, said it would introduce free GP care at the point of access for the entire population by around 2015.

At the outset, it would do this on a phased basis, starting firstly with people with long-term illnesses and then gradually building up the scheme to cover the entire population.

Somebody somewhere hadn't been doing their homework about the legal feasibility of this, as the plan was abandoned on legal grounds last year.

It was replaced with a new plan to introduce free GP care on an phased age basis, firstly to children under six.

While it would have been naive for Minister Reilly to start throwing 'gold' to GPs from the outset to get them to sign up to the under sixes scheme, one might have expected him to display some of the pragmatism that Bevan displayed nearly seventy years ago when introducing the NHS.

Ultimately, one would have expected the Government to realise that at some stage, whatever it might think of GPs as a collective group, it will have to sit down with them to plan the new scheme.

Instead it has done the opposite, and appears hell bent on destroying before it is born its basically sound concept of free GP care for all.

The tactics employed to date by Ministers Reilly and White have amounted to a spin doctor's nightmare.

Every time the Government would appear to have a PR opportunity to portray GPs as standing in the way of better access for the population to necessary healthcare, it drops the ball and gives GPs the moral advantage.

The louder family doctors complain about the under sixes proposals, the more extreme the response from the Government, and the angrier and more resistant the GPs then get. As this happens, the chances of free GP care being introduced any time in the near future are becoming more and more remote.

When the under sixes plan was first announced last year, GPs expressed concern about its ramifications.

Instead of initiating proper negotiations about the scheme, the Department of Health and HSE handed down a draft contract with some aspirational notions that looked good on paper.

However the document mostly contained monitoring and control proposals that no sane worker of any type would sign up to, even if under the influence of mind-altering substances.

Even as an 'opening' management gambit for future negotiations, which could then presumably be watered down or altered, the draft contract provided very little that could be built on.

And this leads us to the next problem with the Government's stance. There haven't been, and are unlikely to be under current policy, any real negotiations.

This stance has been copperfastened in the details of the newly-published bill on the legislation the Government intends to introduce to bring in the under sixes scheme around the middle of this year.

The Bill has been published after the Government had appeared to make some conciliatory noises towards GPs. However, its provisions appear to make make real negotiations on the scheme more remote than ever.

The IMO has described the planned legislation as 'draconian' and really, this description is not far off the mark.

It effectively allows the Government to 'railroad' GPs into the new scheme by threatening to remove existing under sixes medical card patients from those who do not sign up to the scheme.

This not only would lead to an income drop for GPs, but disruption and uncertainty for patients.

For example, parents whose children are currently treated by their GP under the medical card scheme, will, if their GP does not sign up to the free scheme for all under sixes, either have to pay a fee to the GP in future, or else move to a doctor who is participating in the new scheme to continue to get free care.

Also, parents who currently pay fees for GP treatment of their children may have to continue to do so if their GP doesn't sign up to the new scheme, or else will have to move to another family doctor.

The legislation also gives the Minister for Health the ultimate right to decide on fees that should be paid to doctors, after 'consultation'. The Government is still insisting that under competition law, it cannot directly negotiate fees with GPs and that GPs, as a group of independent contractors, cannot as a group collectively set their fees in this way.

Whatever the need to keep an eye on the public purse, the notion that any Minister can almost at a whim decide unilaterally what someone should be paid without recourse to any negotiation or real consultation appears somewhat undemocratic to say the least.

The IMO claims the Government is employing a self-serving interpretation of competition law and claims that as a union, it has a constitutional right to negotiate on behalf of its members. This issue is set to be decided on shortly in the High Court - another factor which will delay the introduction of free GP care anytime soon.

Whatever the ins and outs of competition law, one could argue that if the Government really wanted to resolve the impasse over negotiating rights, it could simply change the law. However, recent proposals for changing the Competition Act included no plans to end this anomaly about independent contractor negotiating rights.

The Government's tactics in the GP row to date seem to boil down to simply issuing diktats intended to alienate the people it will ultimately need to operate the new scheme.

If a reasonable proportion of GPs decided to opt out, then the viability of the under sixes scheme will be questionable and the inconvenience to patients will be considerable.

If is difficult to understand the Government's policy to date on this issue. Perhaps it is mindful of the 'giveaway' deal for GPs in 2002 for the over 70s medical card scheme, whose costs escalated rapidly, and it doesn't want a repeat performance with the under sixes scheme.

This deal, was, of course negotiated on behalf of the IMO by the current Health Minister, in a previous existence.

Also, the Government is obviously realising that with the recession coming to an end, the risks of pay inflation damaging any economic recovery are very real.

However, it should be pointed out that Minister Reilly has for some time being saying that he plans to transfer resources from hospitals to GPs so that they can take on extra workloads, presumably to ensure that any additional payments to GPs would be 'budget neutral'.

However, there is little sign of this transfer of funding happening anytime soon.

And despite the lip service that the Government pays to GP in terms of their crucial role in keeping people out of the more expensive and less efficient hospital service and improving the health of the nation, it stills seems to distrust GPs.

It certainly doesn't like their independent contractor status, or their potential role in driving up drug costs, and perhaps would prefer them all to be salaried State employees.

Whatever effect the current machinations are having on GPs, the Government is certainly doing patients no favours in the way it is planning the under sixes scheme.

Many parents will be wondering if the scheme will ever be introduced, and if it is, whether they will be easily able to find a GP who will operate it.

The under sixes debacle in many way typifies the type of confusion and chaos that has marked many aspects of James Reilly's performance in the health portfolio.

He needs to go back to the drawing board and rethink the whole approach to what on paper should be a popular initiative, but is rapidly turning into a logistical nightmare.

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