Why Are GPs Not Happy About Free GP Care For Under-6s
On the surface at least, this scheme is great news for parents, and most GPs will get a financial boost from participating (myself included), so it may seem strange that most GPs are not happy about signing this contract.......,.
Why Are GPs Not Happy About Free GP Care For Under-6s
As you will know, the Irish Government made a promise some time ago to give free GP care to all children under the age of 6. It is their stated intention that this scheme will be operational by 1st July 2015, whether GPs are on board or not, with further age cohorts to follow. I reluctantly signed the Under-6s contract today (under duress).
On the surface at least, this scheme is great news for parents, and most GPs will get a financial boost from participating (myself included), so it may seem strange that most GPs are not happy about signing this contract.
This is a watershed moment for General Practice (moving from 40% of the population having unlimited free access to GP care towards 100%), one which many GPs fear the country will regret in years to come.
Not this year, as life will go on as normal, but in 5-10 years, when demand increases from 24 million consultations per year to maybe 36 or 48 million – because the service is 'free'.
We know we can't invent the time for these extra consults, so we will have a lesser service, NHS-style, and you may lose the quality of service you currently have.
GPs seem to be the only ones aware of all these risks.
Let me be very clear though, this is not about GPs not wanting children to have free GP care – as most GPs would love a system which reduced the financial burden on any of our patients, (especially those who struggle to pay for the service).
We already very happily treat all babies free at point of delivery for their 2- and 6-week check-ups and all of their routine childhood immunisations, along with all medical card holders, through other state contracts.
This is about Government giving away unlimited chunks of our unavailable time to 100% of the population without planning. They just happened to start with Under-6s when other groups failed.
Your local, accessible and trusted GP service may become a thing of the past (especially in rural areas).
GPs feel they have been bullied into signing this one-sided contract and you deserve to know a bit more about it.
GOOD OLD DAYS
Up until about 8 years ago, GPs in Ireland had demanding, stressful but fulfilling jobs, and earned a fairly good living.
So we didn't have to stress about the business end of things, as there was generally enough coming in to pay the staff, rent, indemnity, and all other random costs.
That meant that in general, we had all the time in the world to look after whatever each and every patient needed.
Most invested in our premises along with extra equipment to be able to offer extra services.
We often sutured wounds, ran warfarin clinics and did lots more to keep patients out of hospital. GPs did lots of uncontracted stuff for 'free' (blood tests, chronic disease management, writing reports etc) because the business could sustain it, we took pride in the service and it was good for patients.
Private patients benefited from public money which subsidised running both sides of the business.
Then the financial crisis happened and GPs were hit harder than practically every other sector for some reason - probably because we had no union protection as we are self-employed, so the powers-that-be kept hitting GPs with cuts to funding for medical card patients (under FEMPI legislation: Financial Emergency Measures in the Public Interest) as they kept getting away with it. 5 times. This totalled a 38% gross cut to business income.
Income. Not profit or GP wages as it was presented to the public.
They cut the funds that paid for the service.
Depending on what staff you could let go or whether you could stop paying rent and indemnity, this meant a net cut of far more than that to the GP.
There was the option to resign the public contract if you didn't like the cuts, but then you would be unemployed along with your staff (and have to pay redundancy to staff).
You could look for a fairer price from a different Irish Government - but there isn't one.
So most ploughed on, under ridiculous pressure to keep providing high quality care 24/7. General Practice turned from being a vocation into a business, with more focus on keeping afloat while still putting patients first and resisting waiting lists.
Services have been slashed, the 'pro bono' work is gone, overdrafts bottom out, GP emigration is climbing alarmingly, and the morale and stress levels have hit rock bottom. All we could do was wait for the long-promised 'new contract' to reverse the crisis.
Then, instead of reversing FEMPI as the economy recovered, the Minister of the day, James Reilly, announced that GPs would give 'free' care to everyone.
He made a few attempts at different cohorts, most failed, then Under-6s stuck.
He didn't talk to us. Nobody did.
His successor, Min. Varadkar eventually spoke to one union in 2014/5, but not the other one. The HSE produced a truly horrendous first draft in Jan 2014 (http://www.galwaybaymedicalcentre.ie/blog/10/General-Practice-in-Crisis).
and now here we are with a tweaked version of the 1970's model, still wrong on so many levels.
I welcome the principle of Universal GP Care, free at the point of access for everyone.
It's a noble idea and would make life easier for many people who struggle to pay to see the GP. Many of my patients will benefit immediately so I really welcome that.
In addition, our practice will earn more money in the coming months as a result of the Under-6s contract which is badly needed... but I still don't agree with the way this is happening.
In theory, it should make life easier for me as a GP, as I could see patients as often as they like or need, without worrying about who can pay for it which is often a factor now.
That would work if I had endless time to offer the thousands of people who I care for. But I don't. Time doesn't work like that. It's limited, unlike the demands on it which are unlimited and getting worse. That's the commodity we are selling - time.
Time with an unbiased professional GP who just wants to get you better, quickly, but needs time to do this safely. There is never enough time.
Everything requested of me might 'just take a few minutes', but if I have 30 appointments daily with 2-3 problems each, then 30 other jobs daily (lab results, letters, phonecalls, scripts, reports, housecalls), there simply isn't enough time to do everything.
I postpone less urgent things but some are shelved for weeks as more urgent problems always appear.
The only people who know how General Practice works, and what it is we do all day, are GPs.
An appointment with a hospital doctor also takes 'just a few minutes' but have you noticed the waiting list for it?
Hospitals love managing time with waiting lists, even for something as simple as an opinion from a doctor that 'just takes a few minutes'.
GP services are currently far more patient-centred and patient-friendly, but this is at risk when control shifts to the HSE and is made free for everyone without resources to back this up.
THE SAME........ BUT FREE
The problem is the assumption that when you make this service free at the point of access, nothing will change and if it was just an occasional free consultation that might be true. Unfortunately that is not likely to be the case with a move from 40% to 100% population-based medical care, where the demand for appointments will rocket in years to come, when the service becomes 'free' for everyone.
When you remove a financial barrier, people use the service more and there is research to prove this.
With no extra GPs (likely less), appointments will be shorter, or subject to a waiting list, or both.
Faster consultations are rushed consultations. Rushed consultations are more likely to be unsafe.
Politicians and HSE managers don't care about quality of care, just cost.
GPs do care, and are also responsible for the quality of that care.
Access to GPs and quality of care will plummet as the percentage offered unlimited free care rises in years to come. Look at the examples of the NHS in the UK, and the apartheid-like difference between access to public hospitals (run by the HSE) vs private hospitals in Ireland.
Many now-dysfunctional GP systems (NHS included) wish they could revert to systems like our current one, with 15-minute appointments with your chosen/trusted GP without waiting lists, but they can't.
The very system we are now trying to get rid of.
FREE CARE FOR EVERYONE
GPs seem to be the only ones who are worried about the pressures of providing free GP care for everyone, in a system where hundreds of GPs are emigrating every year because the stress of running a non-viable practice here drives them out.
We know Under-6s are just the first group to be promised free care.
I get a knot in my stomach every time some politician makes another media statement about the next set of people to benefit from free time with GPs - time that is not theirs to give away, control or promise to others without negotiation.
GPs are responsible for magicking up the extra hours required every day to deal with the stressful workload forced on us - not politicians...
THE MORE WE FIX, THE LESS WE EARN
A big issue for all GPs is availability of time - a precious commodity in recent years. The service is at breaking point and has no more capacity.
If the Government agreed to just foot the bill for each consultation (or ideally some combination of capitation and fee-per-item), that might go some way towards resolving the issue, as we could still try to hire more doctors if more consultations brought in more funds as well as more demands to the practice. (However, there is a manpower crisis, so that wouldn't work until you convince GPs this is a good system to work in).
But instead they offer a flat fee (€10 a month) regardless of how often a child presents, like the archaic contract we already have but the rate has gone up a bit.
So the more children we sign on, the more money comes in; but the more often those children come in to be treated, the less money the practice earns, yet the overheads are rising.
Conversely, the more private patients we treat, the more the business earns. Yet we treat patients equally and without waiting lists – unlike the rest of the health service. That is one of the most valuable aspects of Irish General Practice, and relies on a private/public balance which is now up for deletion.
The longer we spend in a consultation, the more money the practice loses (every practice has different costs). It's not a logical business system (unless you are the Government).
Yet GPs treat patients equally and without prejudice.
The core problem with General Practice at the moment is that for every GP job there is the workload for two GPs, the responsibility and stress levels for three, and the income for one.
We have a manpower crisis which is getting worse by the month due to GP positions in Ireland being so unattractive (exacerbated by the workforce becoming predominantly female - who prefer not to work 60-80 hours a week and because of childcare commitments, simply can't).
Ireland trains some of the highest quality GPs in the world, then exports them to countries who treat GPs with respect.
Respect does not just mean appropriate income, it also involves provision of sufficient ancillary services for patients such as access to consultants, clinics, counsellors, psychologists, A/E, investigations, surgery, physio, dietitians etc in a timely manner, unlike here.
Two-way communication and engagement with management and political structures exists in some countries as does a patient-centred approach to healthcare provision - all of which would make life as a GP easier, not to mention far better outcomes for patients.
There is very little in this contract which would attract new GPs to set up a business or take over from a retiring GP.
Many younger GPs have zero interest in the stress of running a business, they may prefer to emigrate or be employed by a contract-holding GP - but usually only in major urban centres, or wherever their mortgage and family are.
GPs all over the country struggle to find a locum GP to help manage the workload, or take time off.
Unlike our hospital colleagues, the HSE do not arrange or pay for this cover.
The resources on offer in the old or tweaked new contract don't even come close to the cost of providing the service if you have high set-up and running costs (as many GPs have), not to mind hiring extra doctor help to reduce burnout risk.
This is very short-sighted, as we all know the emigration of GPs needs to be halted.
There are great GP jobs on offer in Canada, Australia, and the Middle East.
I used to promote this specialty, but would now advise against it, at least in Ireland.
There are much easier ways to earn a living.
I still love what I do, but hate how the actions of HSE and the Department of Health have made General Practice so dysfunctional and stressful.
The Government/HSE alliance have encouraged the view that this is just an issue of money, that GPs would prefer extract cash from parents than the State.
This couldn't be further from the truth.
We would love if nobody had to pay at the desk. We could stop dealing with patients as customers and the service could continue the same as before.
I've already said most GPs are likely to be a little better off if they sign this contract than not to sign it.
So you have to trust us that there is a lot more to it than that.
That's not to say that money is not a factor when you are planning healthcare.
It is in any business. The first 10-20 years of running a GP business (after the 11 years of becoming one) are often not profitable.
We have almost a lottery system every month, wondering if the payments coming in on the 15th of the month from the HSE (the 'pink form') will be enough to meet the variable costs of running a business.
In 3 of the last 6 months, it wasn't enough in our practice (same in many practices) so the fixed costs get paid and the owners don't.
That's business but if you intend trusting GPs with providing 24-hour medical care to the whole population, it is kind of important that there is enough income to meet the running costs, including premises, rates, staff, insurance, computers and paying the doctors, to name but a few.
The current contract, dating to the 1970's, does not do this (it did before FEMPI).
For example, the amount payable to a GP for doing a housecall since FEMPI is €0 - even if it is 10 miles away (ask your own GP if you don't believe me). The amount paid to look after one such patient barely covers the cost of visiting them once in a year.
Rural GPs, doing an amazing unappreciated job, will be extinct soon.
Losing private practice is also a problem, but not just for GPs. Patients will suffer too.
Running our own businesses incentivises GPs to work harder, be always available, and ensure that enough money comes in privately to help meet the running costs. It may be profitable for some GPs, but usually it just balances the expenses of running the public side. Without private practice and GP autonomy, this service risks blending in with other dysfunctional inaccessible parts of the HSE.
For example, all 420,000 children under 6 already have 'free' access to Paediatricians in our hospitals. Try accessing them when you need a quick opinion though.
THE REALITIES OF GENERAL PRACTICE AS A BUSINESS
Our business is a fine balance between occasional 'easy' consults, and a majority of much more complex consults - where we lose money the longer we spend with patients. I challenge anybody to try running a GP business, along with fixing people, all day every day. The fixing people part of it is usually very rewarding, the business aspect is a large stressful side-job as an unpaid manager.
HSE managers don't want to know this.
So they make false extrapolations and then base policy decisions around what they THINK we do all day, instead of what we actually do.
In addition, false data is regularly supplied by the HSE to the OECD, which was the basis for the extreme FEMPI cuts.
Once a year, usually well planned and timed to cause the most damage, the HSE release the figures for gross payments to GP practices, presented as salaries rather than the cost of running a small hospital, which many GP practices essentially are.
These figures are usually presented to the public as if the HSE had nothing to do with these payments and are merely releasing them as public information, when in fact, the HSE are directly responsible for paying GPs and are in control of how much we get paid.
In effect, GPs are employees of the state for the purposes of these payments.
You, the taxpayer, pay the €1 million or so annual HSE media office bill, much of which is spent deliberately misrepresenting payments to doctors, pharmacists, dentists and others with negative spin, as if the money wasn't for providing a great service.
Which bring us neatly to another interesting issue yet to be resolved...
All hospital doctors and public health doctors are employees of the HSE.
Most GPs are self-employed, a situation which used to work well, but not recently.
Because we are deemed to be self-employed, we are not allowed to have any say in how much we are paid to provide public services, as the Competition and Consumer Protection Commission are only too quick to let us know. This topic deserves an entire blog post all to itself so maybe we'll come back to that topic.
Once we move towards providing care to 100% of people, paid for by the State, we are essentially 'false self-employed'. However, if GPs become employees and remove the 'burden' of our own autonomy, you also remove the efficiency and access which comes with GP-led services vs HSE-led services.
You don't want this and most GPs don't either.
At Galway Bay Medical Centre, we estimate that the cost of providing a single consultation with a GP is approximately €40 to €45.
If a child with a medical card attends once or twice per year, we make a profit.
If they attend 3 times, we break even.
If they attend 4 or more times per year, we make a loss (every practice is different) but we can't refuse to see them for their 5th visit and neither would we.
The capitation system works on the premise that for all the patients who attend very frequently, there are some others who rarely ever come in.
That is questionable logic and not great as a business model, which is why the new contract is needed.
There is a lot of risk involved signing a contract promising that we will provide limitless time to see people for 'free'.
The GP, not the Government, bears the risk and the burden of responsibility if we miss a diagnosis of meningitis, suicidality, pneumonia, cancer, PE, heart attack, carditis etc - either in a patient who we rush out the door, or one we turn away as we have no appointments left.
Politicians don't lie awake at night worrying about this, but many GPs do.
POSITIVES OF FREE UNDER 6
In the coming months, I predict you won't see too many negative effects of free Under-6 care in some GP practices. The pressure on providing enough GP appointments to meet demand will kick in slowly in some practices, faster in others, and will be an immediate problem in so many who are already beyond capacity.
Life will be better, in the short-term at least for parents who won't have to pay for GP visits for young children and the injection of funds, insufficient though they may be, into General Practice will be welcome and do something to alleviate the financial pressure GPs are under.
Not enough to make up for the haemorrhage of resources out of GP surgeries through 5 FEMPI cuts, but something.
Under 6 year old patients with asthma will now be entitled to scheduled check-ups - the first nod to reimbursing GPs to manage chronic diseases – which is very welcome as we have been doing it unofficially for years.
More may follow, and if resourced and planned properly this should definitely reduce the pressure on hospital clinics.
It's so unusual to hear GPs say no to anything.
As a profession, we are generally the epitome of 'Yes People'. We say yes to everything.
No matter what a patient wants advice on, we engage and help. Any body part at all. Any time. No matter what queries or crises are thrown at us in person, by phone or email, we generally respond quickly.
When you don't understand what happened to you in hospital (or why it's not happening), ask the GP.
If you're bleeding from anywhere, come to us first.
When you need a second or third opinion, ask the GP.
If you are suicidal, we are your best bet.
When you are sick at night, you will always get one of us.
When you are sick during the day and don't have an appointment, we will not turn you away.
If you live in a rural area, chances are your GP is as skilled as a small A/E Department and will say no to nothing (but he/she probably won't be replaced when they retire due to Government errors in making the job so unattractive).
When you need a letter or form filled for anything, ask the GP.
When you have to wait months or years for an appointment with the free public health service, who do you come to for help with managing your symptoms in the meantime?
Yes, that's us too.
We are responsible for cleaning up everybody else's mess, or so it seems to us some days. But I still love it, most of the time.
If Government wants services delivered efficiently in any specialty, who do they go to?
Cervical Smears - GPs not Gynaecologists..
Baby vaccines - GPs not the Public Health Department.
Methadone Services - GPs not Psychiatry.
Certifying illness - GPs not Occupational Health
Weighing children - GPs. Despite the fact that Public Health are also paid to do this.
.....and the list goes on.
GPs happily say yes to everything. Until now.
Trust me, if GPs are so negative about this contract, there has to be A LOT wrong with it.
It may take years to realise just how wrong but Government will have changed by then so that's ok.
PLAN IT PROPERLY
All we ask is to be included in the planning process. To be involved in all aspects so that we can advise on what is possible, reasonable, safe and necessary.
This contract doesn't do that.
It contains all sorts of unreasonable demands, risky clauses and sanctions.
It was discussed with one GP union, who initially said it was a good deal, but later admitted it was the best they could get.
The second GP union was excluded from talks altogether, on the basis that they disagreed with the contract (for good reason it would seem), yet represent about half of GPs nationally.
Many GPs are frustrated that we were not balloted or involved in the decision of whether it was in fact a good deal, or acceptable to members. The ICGP, who are responsible for quality and standards in General Practice have questioned the evidence base for some aspects of the contract and have highlighted other risks.
GPs WHO HAVE SAID NO
It would seem obvious to me that the Minister needs to talk to the excluded union (NAGP) to get these matters resolved, including the current impasse where chunks of the country have no GP available to register Under-6s.
Negotiation could resolve this.
The Minister alternatively could force GPs to accept Under-6s by assignment - a mass issuing of discretionary medical cards. Not to children with serious illness though. To healthy children
Which would be more appropriate?
Which will happen?
Watch this space...
PORTRAYAL OF GPs
Contrary to the above 'Yes People' description, GPs are often portrayed as fat cats, shoving €50s into their back pockets for hours every day before escaping to the golf course.
In reality, most GPs work in the region of 50-80 hours per week, with responsibility for organising 24-hour cover every day.
How much of a private fee they get to earn depends on how high the overheads are.
As a general rule for GPs, if you work 80 hours/week, you will earn a doctor's salary (but suffer burnout), if you work 40 hours, the reverse may be true.
This is not sustainable or fair.
Decision-making managers in healthcare and politicians simply don't understand what we do all day.
They are generally in good health, and don't suffer from multiple health problems unlike the people who we spend most of our time with.
If they need to see the GP, it is likely to be a relatively trivial problem which only takes minutes to fix. Based on this rare interaction, they then assume that a GPs day consists of getting paid €50 for every 5 minute consult and set about finding ways to cut our fees (or so it seems).
We are penalised for functioning well, on about 3% of the health budget.
Conversely, approximately 90% of the health budget is spent on 'free' hospital care, no matter how badly it functions for patients.
In broad terms, 'Free' GP care costs the HSE about €200 per person per year while 'Free' hospital care costs in the region of €3000 per person per annum whether you avail of these services or not.
DIVIDE AND CONQUER
I am so taken aback at just how distressed GPs are about this contract.
I have been to dozens of evening and weekend meetings about this contract in the last year, where many of us tried our best to warn that this needed to be better planned and resourced, but these calls were largely ignored.
Politicians attended meetings nationwide on the same issue (organised by GPs in an unprecedented move), seemed to care, but still legislated for Under-6s (there were some who tried to resist).
I have seen many older GPs truly devastated that the profession they spent decades devoted to, is now due to change forever.
Some signed quickly for their own reasons, many of us resisted as long as we could, hoping that our union could be invited to talk and defer the 100% free thing until it's planned properly.
Opinion polls over the year showed on average that less than 5-10% of GPs were happy to sign up. In a few areas, collegiality has strengthened as we discovered most GPs are very opposed to the changes, and want to protect the same day service we created.
Once about 10% had signed up however, local GPs in every area have been forced to sign knowing that a GP down the road has signed which created the very real threat of losing patients to another GP.
Nobody wants this, as the extended family will probably move too.
Despite decades of good care. Free is free and no parent could be blamed for changing GPs.
The Government not only knew this, they created and abused this situation to force enough GPs to sign up. It's a bullying situation like none I have ever been in before, and would never like to be in again.
True I have an ethical difficulty with some politicians prioritising all Under 6 for the first phase, when they can't afford to provide it for everyone, but I could get over it if it was a well-thought out plan. Which it's not.
The medical council ethical guidelines oblige doctors to advocate for appropriate and ethical use of healthcare funding when funds are limited. This contract is a breach of ethics. It was politicians and HSE managers who invented it, but I am coerced into compliance and breaching my own guidelines and gut instinct.
GPs were advised that if we don't sign the new contract, our existing Under-6s would be removed from our panel on 30th June, along with the approximately €6/month each (before tax) that these patients currently attract to fund the business (with a promise of €10 per month if you sign up).
The NAGP supported a GP who challenged the HSE for breach of contract in this regard, but had to withdraw this week for various reasons, one of which was that the HSE promised that no patients would be removed from any GP 'during the summer period'.
Indicating, to me at least, that the initial threat to do so was legally suspect and they knew it.
In addition, the Government are well aware that by publishing lists of GPs who have signed up, helpfully sorted by county, huge pressure is on unsigned GPs who know that they will lose their patients to other GPs if they don't sign up.
This strategy of bullying GPs into signing by pitting us one against the other is not appreciated by GPs and I think it is undeserved.
GPs spend all day every day advocating for patients supporting those who have been bullied by others.
GPs are the glue that keep the health service together, the only easily accessible doctors on the day you need us, and to be treated with such disrespect has shocked and angered even the most placid among the specialty.
A lot of what GPs are unhappy about is losing autonomy.
We currently are fully responsible for running the business, with some state contracts to provide some services to some people.
Stressful as this has become, we still don't want to lose it, as it is the reason that General Practice works (and public healthcare doesn't).
Our contract is with the patient, not an employer.
When the door closes in a GP consultation, the patient sets the agenda.
Our role is to facilitate, diagnose, advise, advocate and manage.
We don't answer to anybody else, and that is in your best interest as the patient.
Once the HSE start looking for data about what we do with you, then try to control and manage how we do it, everything changes.
This is what GPs are trying to protect and are saddened at the loss to future generations of this quality of service.
Parents, when you register your child online you can opt to sign or not sign consent for data transfer. We wouldn't presume to tell you what you should opt for but the HSE didn't manage to get through the first day of registration for this scheme without a data protection breach. You decide.
SO WHAT SHOULD HAVE HAPPENED
When the country can't afford free GP care for everyone, the Minister should have prioritised those with greater need, and leave the wealthy until last to benefit, not first.
The wealthy have been prioritised at the expense of the poor, and the well at the expense of the sick.
In my opinion, raising the threshold to get a medical card would be fairer, from the current 40% to 50-60% of the population so those just over the income limit would now get free care for the whole family (not my healthy 2 year old and many like him), with discretionary medical cards for more people with chronic illness, high medical bills and complex problems This would cost a lot more so is unpopular with politicians - GP visit cards for Under-6s is very low budget relatively speaking, but vote-winning.
So how will the Government fund 'free' care for everyone?
Probably by forcing you to have private health insurance which only entitles you to public care (which is currently free and inaccessible) with the addition of free GP care (but not medicines).
The Government should have engaged with all GP groups from the outset, to ensure a safe, appropriate and evidence-based system was planned, which wouldn't jeopardise access to GPs for vulnerable groups and wouldn't threaten the future of General Practice.
A new contract has been urgently needed for at least 10 years, one that addresses the real costs and resources needed to deliver care in the community properly, and shift workload from hospitals, with money to follow the patient.
We now have a promise (called the Memorandum of Understanding) between Government and one of the GP unions stating that a new GP contract will follow by Summer 2016 for the whole population.
This promise needs to include all 3 GP representative bodies so the voice of all GPs can be heard.
I can't and don't claim to represent anyone other than myself, but I know that many GPs will agree with at least some of what I say, yet every practice is very different.
This long article could be 10 times as long if I included all the issues good and bad.
It's just a snapshot, but may put some things into perspective.
Now I will put the whole stressful episode to bed. GPs were bullied into a bad deal for the future, we tried to resist.
On the plus side, GP care is now free for Under-6s - a good move for the country only if safeguards are in place to keep this service accessible for the next generation.
That will be decided in next year's contract - another day's work...
Dr Sinead Murphy