Free GP care -'it's not just about pay'

  • Niall Hunter, Editor

Interview with Dr Ray Walley, IMO GP Chairman, on what family doctors, patients and the State want and must get from the forthcoming negotiations on universal GP care:

In view of its recent opposition to Government policy in this area, is the IMO still in favour of universal GP care?

Yes, year-on-year that has been the advocated approach and has been endorsed by members at our AGM. The IMO is in favour of universal GP care free at the point of access. We have always stressed that this is resource-dependent. A 'free' GP service needs to be properly planned and resourced. Research shows that the best outcomes for patients take place when you remove barriers to patient access to healthcare, especially access to GP care.

While it may be official IMO policy, would the public perception not be that not all GPs are in favour of universal access, given that there has been such strong opposition to the Government's policy on extending eligibility?

Well, that depends on whose narrative you put out there. We have not changed our position on this at any stage. It is subject to proper resourcing. We believe that access should first be given to those in most need. I have been asked that, notwithstanding our operational concerns about the scheme, is free GP care not, in isolation, a 'good thing'? The problem with healthcare in this country is nothing can be discussed in isolation. It's the way you introduce this scheme and resource it that is key.

When you say 'resources' are you simply saying GPs want to be paid properly for having an expanded role under universal GP care?

The reason we have been concentrating on the word 'resources' is there is such a low level of funding at present for general practice. Only 2.3% of the State budget goes to general practice. The general practitioner is the hub on the wheel and general practice needs to be resourced properly to deliver this service.

Can you put a reasonably precise figure on the level of resourcing GPs would need were free GP care to be brought in tomorrow?

Ultimately we know the figure the State spends on general practice is only 2.3% of the health budget, whereas for example it is 9% in the UK and 10% in Holland. What we would be saying is that certainly, we need to be upping the budget to the same type of percentage that exists in these countries. But you need to be progressing the spend on primary care separately, and not just purely GP services. If you can't get to see your physiotherapist for shoulder pain within a reasonable time in the public system and you have to attend your GP instead on multiple occasions for painkillers as an alternative, that's not an efficient use of healthcare resources. If we are going to add in a chronic care model, where GPs would, for example, undertake much of the treatment for diabetes or cardiac patients, that would also have to be quantified and priced. It should be pointed out that the success of the universal healthcare system in Holland was built on the development of general practice there over 30 years - the type of development that hasn't taken place in Ireland.

What have been the effects of the recent fee reductions imposed on State payments for GPs?

More than anything else, the FEMPI cuts have restricted the ability of many GPs to provide the range of services to medical card patients that they provided before. Traditionally, one of the strengths of the GP system here is that it has been a 'same day' service. We are still in most areas providing a same-day service. There are usually no waiting lists, you get to see the GP on the day you want to see him. I'm afraid in some areas, this is becoming increasingly no longer the case. Free GP access will increase the need for more financial and manpower resources and ultimately, if those resources do not arrive, for even those GPs who may sign up to any new agreement to provide free GP care (there may be GPs who will not or cannot sign up) you are going to end up with more waiting times to see your GP. It should be pointed out that in addition to the increased clinical workload, GPs also must  perform a considerable amount of administrative work. GPs spend hours during the week and at weekends, doing this type of work. All of this extra workload while being under increasing financial pressure is ageing GPs prematurely, I believe. We cannot continue to whip an already overburdened workhorse. We're not saying GPs are a special case. People in all walks of life have been hit by the recession. What we are saying is we have had a disproportionate reduction in income and this needs to be addressed.

Would the IMO at the very least be seeking a reversal of the FEMPI fee cuts, which have reduced GP payments by up to 40% in recent years?

It should be pointed out that GPs are currently dealing with 500,000 more medical card patients than they were around four years ago, but we are back to the level of resourcing of six years ago. Half a billion euro has been taken out of general practice over four years. But there is a review mechanism for the FEMPI cuts and we have engaged with that. As regards restoring the FEMPI cuts, the Government under Haddington Road has promised that all of that can be revisited, and we will make our case under that process. These fee cuts were disproportionate on general practice. What I would hope is that the  recent framework agreement between the IMO and the Department of Health (which sought to overcome barriers to negotiations under competition law) will give us the ability to provide a comprehensive review of what what it is proposed that we should provide, the resources we need to do so and then put a precise financial costing on what is needed. A new contract with a new range of services will require a new fee structure. Any new payment rates will need to reflect the increased obligations and the costs of providing the service. It could take a five to 10 year timeframe in terms of properly resourcing universal care.

So do you think it will take a decade for universal healthcare to come in?

Well, I think it may take 10 years for universal healthcare to be fully implemented. Universal GP care, whereby financial barriers to see the GP would be removed, could be introduced more quickly but universal primary care, incorporating community services other than general practice, for example physiotherapy etc, could 5-10 years to introduce properly. All of this needs appropriate resourcing. You need to take into account resource issues like that the fact that one in eight GPs are 64 years or older - 12% of the existing number of GPs, and they will need to be replaced, and the reality is that all GPs are overstretched all currently under-resourced. As regards eligibility for services, the priority has to be given to dealing with those in most need first. Minister Varadkar has correctly, I believe, tried to stay away from setting dates for the extension of eligibility for GP services.  As regards negotiations, it might be optimistic to predict significant progress by Christmas but we at least are sitting around the table, which was not happening before.

Health Minister Leo Varadkar has suggested that a co-payment system, under which some patients would pay a small fee towards the cost of their treatment under universal care, could be introduced. Is the IMO in favour of this?

We are opposed to the concept of co-payment. There is a lot of research out there that shows such payment systems are detrimental to optimal care. The current prescription charge is an example of a co-payment scheme. Our position is these charges disproportionately penalise the sickest and most vulnerable patients.

Do you think some GPs, regardless of what might eventually agreed with the Government, will oppose a universal GP system as they are in favour of the two-tier public-private system?

Before the bottom fell out of the private practice system, private practice was cross-subsidising medical card practice. In some cases, where GPs may still have viable private practice, this still happens, but I think that's an increasingly small minority. Logic would dictate that fees in future would have to be at a level to allow doctors to cope with the removal of private income under a universal scheme, and an increase in visitation rates. Basically, we need a contract that meets the modern needs of GPs and patients and if we do not get this, we will continue to see GPs, both younger and older, emigrating. What the modern-day medical graduate wants is to be able to use the skillset that he has been trained for. But it's not just about money and what you are paid. At the end of the day, no matter what field of employment you are talking about, the majority of people simply want to look forward to coming to work and have a fulfilling job. We believe that the framework is now there for us to constructively engage about the future of GP services.

Are there any concrete figures on the number of GPs who have emigrated in recent years?

Firstly, it should be said that there's a big difference between the type of doctor emigration that took place in the past and what's happening now. I emigrated in 1990, but I did so in order to get my training, then I came back. We are now losing fully-trained GPs. Pulse, a medical journal in the UK, recently published a statistic showing that 1,049 trained Irish GPs took up NHS GP posts from 2009-2013. Internationally, we are the highest per-capita provider of trained GPs to the NHS.

Why is there a perception out there, rightly or wrongly, and notwithstanding the fact that GPs here are held in high esteem, that they are still relatively well-paid?

The 'spin' from certain quarters is that many GPs get hundreds of thousands of euros into their pockets each year, but this is far from the case. Much of that is taken up with the overheads of running a general practice in Ireland. It doesn't all go into the GP's pocket.

It will ultimately be up to individual GPs, following whatever talks take place, to decide on whether to sign up to a new free GP scheme. If, for example,  the under sixes scheme was offered tomorrow under existing terms and conditions, what proportion of GPs do you think would sign up for it?

I honestly don't know. We would imagine the percentage signing up will be far greater under an agreed scheme than a scheme that would be foisted on GPs. We are still in the very early stages of how we are going to approach talks on any new scheme. Ultimately, it will be up to each individual GP to decide whether or not so sign up to whatever emerges from those talks. The IMO will give its view on a proposed agreement when all the appropriate assessments are done. An independent third party will recommend fee levels. We will not organise a collected withdrawal of GP services - that has always been our stated position. We are precluded from doing so under European law. I believe the population, the State and GPs basically all want the same thing in terms of the future provision of GP care, What we need to do is have a 'win' for all three.

 


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