This time last year, as College members convened for the AGM, the outlook looked bleak for general practice. Practices were continuing to suffer from the FEMPI cuts and the continuing effects of the country’s financial collapse. There was depressing evidence of a ‘brain drain’ of younger (and sometimes older) GPs emigrating to more rewarding pastures abroad. 

Added to this was the Department of Health and HSE’s continued resistance to putting GPs at the centre of healthcare by resourcing them properly to provide structured care for chronic diseases. The College, frustrated by this lack of progress, had withdrawn from the clinical care programmes.

Adding insult to injury was the Department of Health/HSE unilateral contract document presented early last year, which most GPs agreed, if implemented, would have catapulted general practice into an even darker era. Relations between organised general practice and the Government/ health management reached an all-time low.

Now, with the coming of spring, have come signs of fresh, albeit tentative hope of better times ahead for general practice, although the recovery is likely to be long and slow. This follows the recent agreement between the Government and the IMO, centring on the provision of free care at the point of access to patients under six.

Much public debate has centred on the provision of free GP visits for young children and what proportion of GPs will ‘sign up’ to this scheme. The College’s policy supports access to ‘free’ GP care based on need and not ability to pay, or indeed age group. There would be concerns too about workload from this extension of eligibility. 

However, the College views the under sixes scheme as a move in the direction it is seeking for better access for all to GP care. But more importantly, other parts of the agreement (at the time of going to press only headline aspects of the deal were in the public domain) could provide a ‘game changer’ for general practice.

The terms of the deal providing for specific resourcing for ongoing care of patients under six with asthma and for all patients with type 2 diabetes (see table) mark the first time that a Government has officially recognised the key role of general practice in providing ongoing and structured care of patients with chronic diseases. The caveats would be that this is only a first step in recognising the range of other chronic conditions that GPs deal with and does not yet address the often complex comorbidity nature of much primary chronic care.

There would be concerns too about the inevitable bureaucratic pitfalls that may emerge as these new chronic disease schemes are put into place. Will GPs become slaves to box-ticking targets? Will the new programmes face strangulation from the almost inevitable HSE ‘red tape’? Will the resourcing provided be sufficient to take on Ireland’s chronic disease burden? These questions will only be answered as the new schemes are introduced and develop over time.

While the College believes that this is a step in the right direction, does the new deal represent a new dawn? ICGP medical director Dr Margaret O’Riordan says based on the information available to date, the ICGP is giving it a cautious welcome. 

“It is College policy that access to care should be based on medical need rather than ability to pay. We also support the concept of universal healthcare. The under sixes contract is the first step on the path to this.”

Margaret says the College would have concerns on the increased demand for GP services from the selected patient groups and the potential for this to impact on other patients, such that all patients will no longer enjoy the same day or next day service – a key feature of Irish general practice.

“Where a service is introduced free at the point of use, the international evidence supports the view that it is used more widely. Whether this will prove to be the case with this measure is unknown at this time; however, what we can say is that GPs are already stretched to capacity and any increase, however small, will have an impact on access for everyone. There will be some variation in this depending on the patient population of the individual GP.”

However, she says the indication that the new contract will prioritise chronic care management in the general practice setting and that financial supports are being introduced for this is a welcome development. 

“GPs have proven in numerous health management programmes, such as Heartwatch, that improved health outcomes can be achieved when patients are encouraged to attend their GP for regular monitoring and assessment. Prioritising chronic care management is a significant step in recognising the importance of general practice as the best place for ongoing management of chronic disease for patients, as well as for efficient health service management.”

Cycles of care, as proposed in the new deal for asthma care in children under six and diabetes patients of all ages, are not equivalent to internationally recognised structured care programmes for chronic disease, Margaret points out.

“Diabetes structured care programmes encompass more visits and interventions than are covered in the cycle of care described in this contract. The cycle of care can only be seen as a first step on the road to funding of structured care for diabetes patients in Ireland. The ICGP will continue to advocate for the introduction of appropriately resourced and funded chronic disease shared care programmes.

Tom O’Dowd, professor of general practice at TCD, is in no doubt about the significance of this new agreement. He believes it could turn out to be the most significant health service plan since Noel Browne’s Mother and Child Scheme in the early 1950s. However, he does not believe it will meet with the same fate. 

“I think we are much more enlightened as a profession now and the majority of GPs will accept that people have voted for this. It’s smart politics too on the part of the Government. It is setting up a system it knows is going to be popular because it knows general practice is popular with the public. However, it will be a challenging target for the next Government in terms of extending eligibility further.

“As a GP working in a deprived area, I believe the injection of resources to the treatment of under sixes will make a big difference.”

Tom O’Dowd welcomes the asthma component of the agreement. “Respiratory illness, particularly asthma, along with psychological/behavioural problems, are two of the most common conditions in this age cohort, and this will help GPs deal with one of them.”

With the diabetes cycle of care, he believes there will be a lot of scope for more delegation of work and increased professionalisation of practice nurses. A properly structured patient coding system, he believes, will also be necessary. “There will inevitably be teething problems, but I believe GPs will be more than capable of making this new system work.”

Co Kildare GP Brendan O’Shea believes the new agreement, while by no means perfect, represents a ‘good deal’.

“Up to the summer of 2014, there was absolutely no meaningful interaction between key stakeholders, including the ICGP, the IMO, the Department of Health and the HSE over the previous seven years. 

“Since then, there has been relatively speaking a large amount of engagement. I believe that things are really beginning to happen, and in the interests of public patients, we all need to be fully engaged.

“For me, the most important thing is that the ICGP, the IMO and the Department of Health must actively and meaningfully review the deal at 18 months, to address any obvious flaws, and then build on it.”

Regarding the chronic disease elements of the agreement, he believes this progress is better than no progress. 

“One observation is that the approach appears to be based on single disease-modelling, and this is the wrong way to go. No healthcare system has cracked the morbidity burden of common chronic diseases using a single disease model.” 

Brendan believes there is a need for a model that embraces the care of the complex patient with comorbidities in the general practice setting. 

Co Wexford GP John Cox, who has a special interest in hypertension, points out that the agreement provides for the first time for specific payments for GPs treating children under six who have asthma. In addition, GPs will also receive separate payments of over €100 per diabetes patient per year.

“Thus, the estimated 80,000 patients with type 2 diabetes in the GMS system stand to avail of two annual visits to their GP practice for a structured review of their condition under the new arrangements.”

John says he would regard this support of GPs in the management of asthma and diabetes as a significant step forward in the provision of care of patients with these two chronic conditions.

Ray O’Connor, who practices in Limerick and has a special interest in diabetes, says while the specific details of the deal were unclear but would probably emerge in the coming weeks, he would be broadly in favour of encouraging GPs to look after their own patients with type 2 diabetes by resourcing them to review the patient in a Heartwatch-type arrangement.

“The new deal seems to be providing such resourcing and I welcome it. However, before GPs agree to anything we need to review the entire deal when the details are provided to GPs on an individual basis and ensure that it is feasible for us to sign.”

South Dublin GP Stephen Murphy says while what has been revealed to date about the new deal may look good in theory, he is cynical about what might actually happen in practice, citing the level of mistrust of the HSE that has developed among GPs in recent years.

He said he would be concerned about the workload implications for GPs faced with an influx of more frequently visiting under sixes and fears that in terms of resourcing this workload, the proposed fee levels would at best provide only a modest margin for GPs for a lot of extra work.

Stephen says he would also have concerns about the resourcing levels and workload implications in the proposed asthma and diabetes programmes, but further details of how these will operate were being awaited.

Dr Derek Forde, former GP lead in the COPD Clinical Care Programme, has welcomed the provisions for resourcing asthma care in young children in the agreement as an important first step, which he says is significant, as it is the first time GPs are being recognised and resourced for the treatment of chronic disease in primary care.

“Primary care is after all where most of these conditions should be managed. However, the asthma programme in the new agreement will be a challenge for many GPs in terms of time and organisation, although perhaps not as heavy a workload challenge as some might fear.”

Derek, however, feels most GPs will be able to step up to the challenge. “GPs who are practising according to the GINA guidelines will not find this too difficult a target.”

He says while there will be extra resources now going into GP asthma care with the new fee structures, part of this resourcing will have to go towards extra administrative assistance and practice nurse commitment.

Derek Forde also believes that on the basis of the agreement and its commitment to resourcing chronic disease management in two key areas, the ICGP should rejoin the clinical care programmes. He says if the resourcing and development of primary care chronic disease management now goes ahead as planned, GPs will need some guidance and direction through College input at national level. 

Key features of the new agreement

A total extra investment of around €90 million annually for the under sixes scheme and other provisions.

An annual capitation rate of €125 per under sixes patient will be paid. This will apply to new under sixes plus existing medical card under sixes. Additional subsidies, out-of-hours, pensions, etc will reportedly bring the price per patient up to around €210 per child under six for many GPs. Children under six will receive two ‘wellness checks’ for height and weight.

There will be enhanced capitation payments in respect of children under six, who will be covered by an ‘asthma cycle of care’. These will comprise: 

• Year 1: Normal capitation of €125 plus €50 registration/diagnosis plus €45 (three-month review) plus €45 (annual review) – €265
• From year two onwards, normal capitation will apply plus an enhanced payment of €45 on capitation for an annual review, amounting to to €170
• A diabetes cycle of care will be introduced for GMS and GP visit card patients with type 2 diabetes. This will provide structured care for this condition, on the basis of two specific visits per year to review the patient’s condition. GPs will be paid a registration fee in the first year of €30 per visit, with enhanced capitation payments to reflect two annual visits at €50 per visit. Participating GPs will be required to submit appropriate data to the HSE to enable the effectiveness of the arrangements to be monitored and assessed, according to the agreement.

Other provisions include:

• A new dispute resolution procedure that will apply across the GMS and under six contracts
• An extension of the GMS contract on a voluntary basis to GPs who wish to continue to practice to age 72
• The introduction of flexible/shared contracts for those GPs who wish to share a whole-time commitment.

The free GP visits for under sixes and asthma components of the agreement are expected to be introduced by July, while the diabetes cycle of care programme is expected to be implemented later this year. Also, free GP care for all over 70s is likely to be introduced in the summmer.