The new GP contract was the subject of much debate and discussion at the IMO AGM over the weekend, and the members have supported it. There are more details of the draft contract on the IMO website, but all seem to be in the members-only section. (As I’m a member I can read them, but I don’t think it appropriate to share more widely). The council of the other main GP representative body, the NAGP, met on Sunday, and are reported as having rejected it unanimously. What is going on?
The contract comes out of a year of negotiation, led by the new IMO president Ray Walley. This started when the DoH drew up a draft new GP contract, apparently by looking into their hearts, and launched it in early 2014. The various associations said no, quite unanimously, and after some further talks, the IMO and Alex White drew up a framework agreement for negotiations which was published in June 2014. This framework has led to the current draft contract.
The main features are :-
- Free GP care for all 270,000 children under 6, including two child health checks at ages 2 and 5 (€67m)
- Free GP care for everyone aged over 70, who does not already receive this (36,000 more people) (€18m)
- Two modules for chronic disease care (€4.5m), one for diabtetes, and one for asthma (included in the Under 6’s)
- A new dispute resolution process for dealing with PCRS (these are mostly disagreements about payments)
The total cost (according to the DoH press release) is about €89.5m. These new GP visit cards do not provide for free drugs.
There seem to me to be three main objections, based on reading the media, talking to people, both at the IMO AGM, and elsewhere, and looking at social media:-
It’s unfair to give free GP care to all children under 6, while leaving children over 6 who have health problems, paying for GP care.
If we look at fairness, then the argument that this is unfair has some force. However, there is no easy way to grant access to free GP care fairly. The recent report from Frank Keane and his colleagues on ‘Medical Need for Medical Card Eligibility’ concluded that “In the absence of international objective and reproducible methods of measuring burden of disease and illness, it is neither feasible nor desirable to list conditions in priority order for Medical Card eligibility. A listing approach risks inequity by diagnosis and a further fragmentation of services.” They also suggested that “a priority for the health service should be to use these recommendations as a stepping stone to the implementation of the first phase of the Government’s Primary Care reform programme, providing free GP care for all, with the aim of further ensuring universal access to the full spectrum of Primary Care Services as a matter of course and thereby aligning the health service in Ireland with health systems in other EU Member States”. They argued for a more systemaitc approach, and a more compassionate approach to granitng discretionary medical cards, but not for their general extension to groups defined by diagnosis.
There will be a lot more visits to GPs by parents with small children, so GPs will be swamped, and get paid very little per visit.
The burden of extra visits is much harder to assess. People whom I respect have come to different conclusions about the impact of extra visits, and I do not presume to decide myself. It seems likely that there will be some extra visits, and this reduces the value of the extra capitation fees. This is probably the key business decision for each GP to make. I doubt if it make much sense to continue thinking about general practice in terms of costs per visit. It will be important for practices to come up with novel ways of managing visits from well youg children. There seems to me to be a clear role for practice nurses with an interest in child health and asthma to take on some of this work. In other health services, such as the NHS, such staff are paid for centrally, and this is a model that should be pursued further here. In addition, much closer links between GPs and the community health staff might be a good idea.
HSE will not be able to make it all work, and there will be another adminsitraitve fiasco, and GP’s get to pick up the pieces.
Whether HSE can do the registration is currently a major unknown. PCRS seems to me to be one of the more effecitve pieces of HSE, when it comes to using ICT, and they might be able to do it, if the registration process is simple enough. There is a risk of a mess, but I hope it will not happen.
What are the advantages? I see two :-
First moves towards a single tier health service
The Irish healthservices have been crippled for years, by a peculiarly perverse two-tier health system, with payments for primary care, but free access to many hospital services, and two sets of queues, private and public, fast and slow, for the same services. Many people in Ireland do not realise how twisted and perverse this is, because we all grew up with it. It is also rather expensive, unfair, and quite disruptive. A single tier system would, almost certianly, cost less to run.
First moves towards paying GPs for doing integrated care
Most, if not all, GP’s have been providing integrated care for long-term illnesses for many years. Up to now, there has been no real mechanism to pay for it. The asthma and diabetes care payments are a baby step on the road to properly resourcing GP’s to care for people with long-term illness.
Overall, I’m going with my union (I’m a current IMO member, and a former IMO executive member). I do think that this is a good start, and the first instalment of a useful, and very necessary, increase in resources for general practice.. It is only a start, but it is one of the biggest changes at the sharp end of our heath services in some time.