The IMF has been complaining about Irish GP fees. According to a recent Troika report on Ireland: “Health spending is high here but the results are average, which implies that there is poor value for money. This means that people are dying unnecessarily. There was more scope to extend life expectancy here than in almost any other developed country”.

These opinions appear to be based on a plethora of well presented documents on Irish healthcare as well as general media reporting over the past decade. These accounts on Irish primary care appear to consistently present a picture of Irish general practice having too few doctors to service the population, possibly as a result of restrictive entry practices, which is an opinion shared by the ESRI and the Competition Authority. The implication is that Irish GPs are among the best paid in the world and we are working too little relative to our international peers.

However, despite the official appearance of such reports and their consistent theme, from a working GP perspective none of the figures reflect reality and therefore they deserve to be subjected to a critical appraisal.

This analysis identifies that there is a problem with the production of reliable information on primary care over the past decade as official reports on Irish healthcare are often flawed as a result of good analysis of poor data, or poor analysis of good data. The Department of Health and the HSE do not appear to be concerned that there are major consequences in relying on poor quality data to direct health system change.

A new implementation group has been set up by the Department of Health to plan the changes associated with universal health insurance (UHI). Unfortunately, no general practice representation was included on this group to advise on primary care data.

OECD reports calculate that Ireland had a comparatively low rate of GPs at 0.5 per 1,000 population. This is well below the average in OECD countries of 0.8 per 1,000 population. This internationally accepted figure of the number of GPs in the country has until recently often only counted GPs with GMS lists. However, the 2011 OECD figure, which is based on a new methodology, gives a figure that is remarkably similar to Healthlink estimations of the number of GPs on its system, plus 5-10% GP population not located in areas covered by Healthlink and another 5-10% GPs not being computerised. These are the figures that should be used as the denominator when considering income per GP – not a figure that is 32% lower.

The published income of Irish GPs is meant to reflect the true net GMS income after all legitimate expenses are considered (private income is not considered). However, the Irish GP income figure in comparative studies is derived from the gross national GMS expenditure to GPs which includes superannuation payments minus 20%, which is considered an adequate sum to fund our practice costs. Then, the calculated profit is divided by only the number of GPs who have a medical card list, and not all the GPs who work in the GMS.

Inflated figures

In contrast, UK GP salary figures are published after 60.9% of their gross income is apportioned to practice running costs. They appear to have a defined benefit state pension that is not included in their income calculation. Nor are UK GPs’ IT or out-of-hours overheads fully reflected in their costs. The OECD reports on French GP personal income figures include both part-time and full-time GPs and do not include their superannuation funding. French GPs, who consider themselves to be under-resourced, have 45% of their income credited as running costs. The difficulties with the Irish figures may have resulted in the Department of Health not submitting 2010 data in a timely fashion due to it considering a change of methodology of reporting. Unfortunately this has resulted in an inflated income figure which does not exclude practice expenses.

The NHS National Information Centre can produce national primary care reports within six months of the end of its accounting year, but in Ireland the publication of the 2011 PRCS annual statement was not available until more than 14 months after the year ended. This served to maintain inflated figures in the public domain that were taken from before the 2009-2011 FEMPI (Financial Emergency Measures in the Public Interest) cuts, resulting in a clear over-estimation compared to international comparisons.

Looking at HSE funded reports, the April 2012 Review of the Primary Care Reimbursement Scheme was presented by the HSE to the media as possible proof that ‘ghost’ medical cards are costing the State E65m-E210m every year. A final report on this overpayment to GPs was meant to be brought out in August, then September 2012, but we are still awaiting it. However in November the HSE reclaimed the money it had ‘overpaid’ general practice, which was the total sum of E350,000. Since then, some GPs are finding that they are being refunded most of that money as it was reclaimed in error, and we are still awaiting many other historical payments.

The March 2010 National Review of Out-of-Hours Services by the HSE claimed that the cost of running the national service is E90 million more than the Northern Ireland service (£18.7-£20m). The HSE, however, fails to consider the five-times greater land mass covered in the Republic; the 4.5-times more centres used; the much greater over-70s population covered; the greater medical need of the under-70s with medical cards; the different payment structure for general practice in the UK; differences in the rate of exchange and purchasing power parity, and that all Irish State citizens are allowed access to the service.

Crude rates

Regarding private income, the lay media often presents average GP fees at E60. An earlier report on the Irish health system by the European Observatory on Health Systems and Policies in 2009 costed a ‘typical’ consultation in Ireland at E60-E80. Then the November 2012 European Observatory on Health Systems and Policies Report commented that it cost around E51 per GP visit in Ireland (standard consultation March 2010), in contrast to the GP fee of E22 in France (E23 minimum fee in 2012 of which E22 is reimbursed by insurances). The clear implication is that the French spend a lot less on attending their GP than the Irish.

However, the OECD does admit that the crude consultation rate is not a measure of a doctor’s productivity as consultations can vary in length and effectiveness and this is not taken into account when comparing different jurisdictions’ prices. Also compared to France, we have a higher proportion of practice nurses here, who would attract a much lower fee than a standard consultation.

It appears to be standard practice to compare the average maximum Irish fee to minimum, often insurance-guaranteed fees elsewhere. There is never acknowledgement of the extent we reduce our rates for private patients who are in financial difficulty, our non-charging more frequently for full consultations, reviews or multiple consultations.

Considering those reductions, along with the proportion of complex consultations that occur over the telephone, the true average fee per consultation is probably less than E40.

We have also cultivated a level of telephone consultation that does not exist in countries with insurance-funded pay per visit systems, which encourages a supplier induced demand.

Published statements such as “The State paid an average of E65 for every GP visit made by a public patient in 2008” is dependent on the ESRI accepting an inflated figure of GP payments per patient and a greatly underestimated attendance rate. The PCRS miscalculation of GP income per patient is as a result of adding all the non-GMS PCRS payments to the numerator and not including the doctor visit card patients in the denominator.

The OECD reports a very low consultation rate in Ireland – just 3.3 per capita compared to an OECD average of 6.5 per capita. The low rate is a result of changing the CSO methodology from asking interviewees how many times they attended their GP in the previous two weeks in the 2001 Quarterly National Household Survey (QNHS), to asking a much smaller cohort how many times they attended over the previous 12 months in the 2007 and 2010 surveys. This is despite the European Statistics Office coming to the conclusion in 2006 that requesting patient recollection past one month in European Health Interview Surveys (EHIS) was unreliable.3 The 2001 QNHS elicited an attendance rate in all adults of about five GP consultations per annum which peaked for over 65-year-olds at nine per year. This mirrors many other PCRS, independent Irish and UK study figures. However, more recent surveys which report a much lower attendance rate also contain the totally implausible statistic of GMS patients over the age of 65 attending less than GMS patients in the 45-64 years bracket.

Efficiency and effectiveness

The claims about our health system underperforming cannot be reconciled with proper research such as the 2011 Journal of Royal Society of Medicine paper ‘Comparing the US, the UK and 17 Western countries’ efficiency and effectiveness in reducing mortality’. Ireland ranked first by a long margin when looking at the feasible reduction of mortality 1979-2005 relative to healthcare funding.

About 43% of the national population has a medical card. They comprise the poorer, older and sicker proportion of the population and therefore make up about 75% of the workload in general practice. This year, GPs in Ireland will receive about 3.5% of the total HSE budget (or 2.7% of the total public and private health budget) for tending to that population, when in the UK, GPs, for providing a similar service, will receive nearly 7% of the NHS budget for looking after 100% of the population – the UK is well known to operate very frugally.

I have never seen a report by a health economist where Irish general practice funding was considered as a proportion of the total health budget or proportion of GDP: the proportion of the Irish GDP that is directly spent on GP fees and expenses for the PCRS population (0.3%) is exactly half the proportion of the UK GDP that is given directly to NHS GPs (0.6%), but there are many hidden costs in UK GP funding such as IT costs, superannuation and out-of-hours care that don’t exist in Ireland.

The state has plans to further reduce GP payments by up to E70m this year under the Financial Emergency Measures in the Public Interest Act. This will result in our funding allocation being reduced from 70% of the UK rate, to 60% of the UK rate per patient once the extra work burden of the Irish GMS patient is considered. 

There is a fixed national budget for healthcare. Damning but not very accurate ‘evidence’ put into the public domain is used to support the current HSE policy of subjecting Irish general practice to a series of resource reductions. The administrators who enforce these massive cuts in our gross rather than net income justify them on the basis of this manufactured data. 

A Competition Authority spokesperson has said that GPs have noted publicly their objections to the various FEMPI cuts, but service provision has not been affected. However, in the media and in the Oireachtas there has been much talk about GPs charging GMS patients for services they previously provided pro bono.

GPs, with nursing and administrative staff, are working hard to provide a patient-centred, holistic, cost-effective and professional service to all, irrespective of their background. Often, we are patients’ most effective advocates. Are we expected to suspend our skills of critical analysis and accept these flawed reports used as justification to unfairly reduce our income? These reductions have the capacity to do great damage to a health system that we as GPs have put so much effort into developing.

Reliable and unambiguous evidence

It is important that the evidence should be reliable and unambiguous before any significant national change in the health system is mandated. 

The current reporting of healthcare data results in the creation of a public relations environment that is hostile to the resourcing of general practice and enables a diversion of health resources away from where they would be most cost effective. However, I am somewhat heartened by the most recent OECD Health Data report, in which Prof Frances Ruane identified the poor reliability of publicly-produced statistics in Ireland. He also questioned “policy-based evidence-making”.

We GPs should be questioning public service administration efforts to drag us down a corporate route that is justified on the basis of greatly flawed health reporting. Corporatisation has been proven internationally to statistically increase the costs of providing care with no obvious benefits to the patient. As patient advocates and involved professionals, we GPs should demand that health data is more reliable, oppose illogical health strategies, and get involved in the discussion about primary care at an executive level.

References

• European Commission. Occasional Papers 127  January 2013. Economic Adjustment Programme for Ireland Autumn 2012 Review. doi: 10.2765/4044
• Winter J. Health and Social Care Information Centre. Investment in General Practice 2007/08 to 2011/12 England, Wales, Northern Ireland and Scotland, 26 September 2012. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/inve-gene-prac-eng-wal-ni-scot-07-12/inve-gene-prac-eng-wal-ni-scot-07-12-rep.pdf
• Winter J. Health and Social Care Information Centre , GP Earnings and Expenses 2010/2011, 26 September 2012. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/gp-earn-expe-2010-2011/gp-earn-expe-2010-2011-rep.pdf
• McDaid D, Wiley M, Maresso A, Mossialos E. Ireland: Health system review. Health Systems in Transition, 2009; 11(4): 1 – 268 ISSN 1817-6127
• Thomson S, Jowett M, Mladovsky P (Eds). European Observatory on Health Systems and Policies. Health system responses to financial pressures in Ireland: policy options in an international context. Final report: 16 November 2012. http://www.dohc.ie/publications 
• The Competition Authority. Competition in Professional Services. General Medical Practitioners, 2010
• European health interview survey (EHIS) - collection round 2008. http://epp.eurostat.ec.europa.eu/cache/ITY_SDDS/en/hlth_ehis_esms.htm
• Ruane F. Administration 2012 (60):2 119-138. http://ipa.ie/pdf/Administration/FrancesRuane.pdf
• Ruane F. Irish Times, 2013 (Mar 13): Public policy must be based on evidence and not on ideology or anecdotes. http://www.irishtimes.com