Standing guard against ‘perfunctory medicine’

‘Perfunctory medicine by perfunctory men’. This was the fear expressed by Clifford Albutt at the time of the introduction of the Social Insurance Act in the Britain of Lloyd George a century ago. It is a prospect that frightens Irish GPs considering extension of GMS care to children in 2014. 

As the first step in the planned introduction of universal health insurance, the proposed contract for GP care to children up to age six is bound to be seen as a weather vane. Its ample condemnation by GPs has been widely reported. Yet, it is surely not the place of doctors to presume to tell the Government what the people want. In Ireland, as  in Britain, Sweden or other countries which have effected radical changes in the milieu in which doctors work, emigration or adaptation have been the only options open to the profession.

How then do we square the circle of facilitating the settled policy of our Government, with the least risk to the  future of the service, so that the policy does not fail both medically and politically? I believe that there are three sorts of considerations that must be weighed when looking at the under sixes project as a template for the ultimate extension of eligibility to all patients in primary care. Firstly, there is the question of how any proposal will affect practice income. There are also political and strategic professional aspects that must be examined.

Practice income

Each practice that will be invited to participate in the proposed scheme must consider what resources it would need to meet its requirements. If we concentrate on the essentials of the proposal, what is required will be for GPs to surrender a quantum of private fee income directly related to the frequency with which children consult, and to accept instead a fixed capitation package for open-ended availability. 

If we must also factor in time taken out of direct patient care for mandatory audit, periodic health checks, participation in primary care team meetings, or any of the other desiderata of the draft contract, the equation becomes unwieldy. Taking just the narrow focus of capitation in exchange for access to a GP or practice nurse, in my practice of eight GPs with an active patient list of 18,000, the calculation runs something like this:

• We have 1,052 non-GMS patients in the under six age group, who consulted a mean of twice in 2013, excluding visits related to immunisation and the Mother and Infant scheme. The 599 GMS eligible patients in the same age cohort consulted a mean of 4.1 times in 2013.
• It seems likely that the consulting rate of the newly eligible under sixes would rise to meet that of the existing GMS group. Leaving aside visits for mandatory health screening, this would require an additional 2,100 consultations per annum. As the principals make an average of approximately 5,000 face-to-face consultations each year, there would be a need to recruit at least a half-time doctor to meet the demand generated by the new contract. The private fee income generated by the 1,052 patients in 2013 would also have to be replaced and this equates rather neatly with another half GP assistant salary.

From the foregoing, it is apparent that my practice would need to recruit a half-time GP at least, to say nothing of providing the office space, equipment, reception cover, nursing support, or the cost of the additional complexity  of the practice in terms of payroll, accountancy, leave and other entitlements.

Interestingly, the private fee income at present works out at an average charge for children’s visits of about €20, half the nominal fee. This presumably reflects a widespread practice of waiving or reducing fees when several family members consult together, when the consultation is a review visit or when there are other grounds for leniency. This flexibility may not be generally appreciated in society. On the one hand it undermines the argument for providing free care, although on the other, it could make a deal more affordable to Government.

However, this deliberation happens in the context of a further round of FEMPI cuts across the GMS, which will subtract, I estimate, another €90,000 from our budget, again a figure close enough to the cost of an assistant’s salary.

Were a proposition to emerge that provided fully for the cost of additional capacity, replaced lost private income and reversed the impact of the latest FEMPI cutbacks, there might be merit in considering a proposal on the under  sixes. However, it seems to me that a merely budget-neutral formula would not be any sort of incentive. 

Political considerations

Our Minister for Primary Care has stated that the cost of bringing a child to the doctor is a barrier between the citizen and medical care. It is not for any doctor, or even congress of doctors to gainsay him. 

What can be pointed out by doctors as individuals or collectively, is that the manner in which the State has chosen to treat with them is unacceptable and inconducive to the success of any proposal. In my opinion, the degree of mistrust that now exists between the Government and GPs as contractors is of itself a guarantee of failure, whatever financial salve is applied to the problem in advance of an election. Persistent and repeated undermining of practice income under the FEMPI process has been a declaration of war on good manners between the two sides. Some guarantee of the agreed level of fee income would have to be given for any new contract to be acceptable to doctors.

The damage inflicted by the FEMPI process has been compounded by an apparently high-handed approach to the proposed extension of GMS eligibility. It is offensive to doctors that they should be denied a collective voice in the course of planning these changes, let alone in any negotiation. If it is not wholly reasonable to assert that this administration finds the strictest interpretation of competition law a convenient excuse for avoiding negotiation, neither is it unfair to remark upon its lack of hurry in changing that law.

What astonishes is that it could be thought possible to introduce such a major change in eligibility with little prior consultation and without any negotiation. 

Furthermore, the comprehensive array of new collateral obligations on GPs that is proposed in the draft contract will be a very hard sell. Audit, PCT membership, and health promotion may be fine ideals, but frontloading an agreement with these and other new conditions in the current climate is not calculated to attract providers.

Professional strategic considerations

When the NHS was debated by the British Medical Council in 1946, the profession feared that a de-facto medical civil service in general practice would rob the patient of the advantages of an independently minded, patient-centred, personal physician, and provide a bureaucrat as replacement. This doctor, transformed into a technical officer of Government, would depend for career progression on the values of the civil service, among them risk aversion and deference. There is a foreshadowing of these concerns in several aspects of the draft under sixes contract. 

Sixty years on and NHS GPs are still proud of their independence. However, they are subject to a degree of management oversight that is very alien to the Irish GP.

It is very clear to me that Irish GPs have long shared a common vision of what general practice ought to be. They are trained and interested in managing patient concerns in that trackless domain of human illness. Their patients have repeatedly expressed satisfaction with what is provided. 

It is today unfashionable to consider that the professional ethics of the medic might be a better assurance of good  conduct than the policing of compliance with guidelines. Yet no protocol, however elaborate and intrusive, can ever hope to map out every part of a clinical encounter.

I believe that most patients in general practice, would rather trust the professional ethics of an independent  doctor of their own choosing than the remote superintendence of a salaried medical technocrat, who is unwilling or unable to take risks for their health.

That is not to say that a salaried practitioner cannot be highly professional, but only if he is  provided with the conditions for reflective practice. Those conditions seem to be the least likely outcome of a contract for service with open-ended availability. Where the GP must rush his patients to make his living, the patient will get no more than what his Government pays for, regardless of what may be written in the small print of the contract.

Any Government which pretends to assume total control of the system of general practice in Ireland must be prepared to bear the cost of creating and maintaining that infrastructure. This cost is likely to be vastly greater than the millions ring-fenced for the under sixes contract. The draft proposal is a template that sees the GP constrained as though an employee, but retaining the burden of building, equipping and staffing his place of employment.

Of course, the Minister will be well aware that any extension of eligibility will cost money. Within six months of the announcement of the Choice of Doctor Scheme in 1972, it became apparent that the costs were at least double those forecast. Likewise, estimates of the cost of the over 70s medical cards were inaccurate. Were such a miscalculation to become apparent, what damage might that do purchaser-provider relations?

Where GPs used to see 20 patients per hour under the old pre-1972 dispensary system, working with little more than a stethoscope and a biro, they have since been allowed and even encouraged to emulate international best practice, seeing perhaps six or seven patient an hour with access to a  range of equipment and supports unimaginable in 1972.

In my opinion, there is a risk that an unrealistic assessment of the capacity of general practice to absorb workload under the under sixes initiative will see a gradual regression to a two-tiered experience of service provision in general practice. 

Possible solutions

In short, the economics of participation in the draft scheme for the under sixes will be critical for each practice. The Government provision may underestimate the true cost of extending eligibility. The GP, even were he or she tempted by the nominal fee when it is announced, cannot at this point have any confidence that cost over-runs will not simply be clawed back under the FEMPI process.

This is an initiative born out of political expediency in the least propitious circumstances for agreement between GPs and the Department of Health. The manner in which the project is being moved must be a trigger for the professional to stand up as an individual for the right to representation and in unison with colleagues against the setting of a fatal precedent in the planning of our future health services.

How could this situation be rescued?

We must act so as to require the Minister to step back from the draft contract and address the unacceptable process by which it has been introduced. If this requires an emergency legal corrective to the law of competition, let that be undertaken promptly.

If meaningful dialogue with the profession can then follow, we might start by questioning the need to select an upper limit of age six. Might the Minister consider a stepwise introduction starting with children up to their first birthday? Could a simple extension of GMS eligibility without a new form of contract be a better prescription, recognising the contractor status of GPs without seeking so many of the controlling measures? If the GP is to continue as an independent contractor, might the State not simply subsidise the patient’s private fees to a limit that fits with its budget?

In the longer run, if we can set the discussion about care to the under sixes on a mutually respectful footing, there is room to hope that the proposed wider changes to primary healthcare can be delivered safely.