Health Minister Leo Varadkar has a map in his office that has been updated regularly to outline the geographical spread and numbers of GPs who have signed up to the controversial under sixes agreement. This dotted map essentially provides a snapshot of the significant changes ahead for GPs and their patients. He spoke to Forum on May 28, as a heated and sometimes divisive debate about the under sixes contract raged among GPs.

Leo Varadkar, however, is adamant that GPs and the health service are facing into a more hopeful future. He indicates that GPs may be pushing an open door in terms of seeking further resourcing and funding to allow the specialty reach its full potential in the years ahead.

While GPs will understandably be suspicious of Ministers bearing gifts, Leo Varadkar’s vision is far removed from the dark ages of the FEMPI cuts and unimplemented policies of his two predecessors. Future developments, according to the Minister, are likely to include expanded/enhanced  STC and out-of-hours payments, a revamped practice development/drug budgeting scheme, reversing the FEMPI cuts and the development of new chronic disease cycles of care next year. So are happy days really here again?

Contract deadline

At the time of the interview, June 5 was still the official contract signing deadline, with the Department of Health claiming just under 1,000 GPs had signed up at that stage.“It’s not a drop-dead deadline,” the Minister stressed. 

“I want GPs to sign up by the fifth of June, because what will happen is parents will go on the (HSE) website after this date and they will be looking to see if their GP is willing to provide the new service. It’s in the interests of GPs to be there on day one, but that’s up to themselves as individuals.

“If GPs are a bit late in signing up they are not going to be turned away – not at all.”

As for the ‘gun to the head’ tactic whereby GPs stand to lose medical card patients if they don’t sign up: “First of all, the key thing to remember is patients come first in all of this and patients have the right to choose their GP within reason, so it has always been the case that the patient can move to a different GP; that’s true for private as well as GMS patients. If GPs aren’t willing to provide this enhanced service for their existing medical card patients, I would understand why those patients would want to move to a GP who is prepared to provide the service. It’s always important to see this from the point of view of patients.

“We’re not going to reassign existing medical card patients to another GP during the transition period; we’re going to allow for the summer period to pass.” 

The thinking behind this is to allow for a reasonable transition, the Minister said. “It’s not our wish to reassign huge numbers of under six patients from one GP to the next; we want all GPs to sign up and then give patients the choice and freedom to choose their GP, just as private patients can now, so that’s what we’re trying to do.”

On the legal issues involved Leo Varadkar says: “It’s important to bear in mind that the Government is the Government and it makes policy and the Oireachtas makes the law. That’s something that most people in society accept and when the Government brings in a new scheme, that applies, and at a certain point the old scheme has to end. For example, when free secondary education was brought in (in the late 1960s), schools that used to charge at a certain point had to stop doing that; when the Mother and Child scheme was brought in back in the 1950s, the old arrangements couldn’t continue forever. So when you bring in a new scheme to replace an old system, sooner or later you need to shut down the old system.”

Asked would he not agree that GPs, like patients, have freedom of choice and was it not unfair to penalise them financially for exercising that right, the Minister replied:

“They do have freedom of choice but what has to be understood is that we can’t leave an old scheme in place forever; contracts change over time. Could a teacher, for example say I’m on this contract signed in the 1980s and I want to keep it forever? It’s not how the world works.”

He believes most GPs will have signed up by the time of the planned introduction date in July. “Once the website (informing patients about the scheme) goes live, which is around June 9, within a week or two of that I believe most GPs will sign. I believe the majority of GPs will want to provide this service to their patients and will want their patients to stay with them. I think a lot of new and establishing practices will want to gain patients.”

Higher payments

Minister Varadkar believes the new higher under sixes fee and the new payments for asthma and diabetes cycles of care will help provide the resources for GPs to cope with the extra child patient workload and to deliver chronic care.

“The new under sixes payment represents an increase of about 80% in the fee, which is very significant. It’s the reversal of the FEMPI cuts for that (patient) cohort. In my view it’s only the first step. What I want to move on to now very quickly is negotiating further enhancements in primary care services, the unwinding of the FEMPI cuts, a reformed system for STCs so that it’s economic for GPs to do things like suturing in numbers they don’t currently, to do 24-hour blood pressure monitoring, etc.

“Some people are talking about renegotiating this contract. That’s not the space I’m in at all. What I want to do is move on immediately and start negotiating further enhancements – improvements to out of hours, improvements to STCs, taking in more chronic diseases, etc.” 

He emphasised that any further changes will be done by negotiation. 

“There will be no draft contracts appearing on websites. Realistically, what we will need to do after the new service comes in, is to audit it after a few months. I know GPs have concerns about increased workloads and increased attendance – I don’t think the increased attendances will be as great as people think, but we will need to see (what happens).”

Chronic care expansion/FEMPI reversal

On the further roll-out of free GP care, he said he wouldn’t expect GPs to agree that it be extended to all primary school children (six-to-12-year-olds) in a few months time. 

“I think that might take a little bit longer. I would see the next couple of steps being revised and enhanced STCs to cover more procedures, I’d like to see the first unwinding of the FEMPI cuts in line with the unwinding that’s going to occur for public servants. Also, more chronic diseases being looked after in general practice for those who want to do it.” 

He feels COPD and chronic cardiac failure could be the next areas to be covered in chronic disease cycles of care.

“But that’s my view, I’m totally open to the representatives of the doctors and the College coming forward with their own proposals.” 

The Minister feels these areas should be looked at before the introduction of free care for the six-to-12 age cohort.

“That’s my personal preference, but I’ve never been hung up on the sequencing. What’s important to me is the end result, which is better access to primary care for many more people.”

On the further rollout of chronic disease care programmes, he stressed that he would welcome the views of the College on this. He said in many ways the reason why diabetes was included as one of the initial two cycles of care was the advocacy of Velma Harkins and the College, and he feels the further expansion of chronic disease programmes could be implemented next year. 

As to the timing of the introduction of a new overall contract, he said he cannot predict what is going to come out of negotiations before knowing the position of the other side. 

“You could go one of two routes, which would be a whole new contract that covers absolutely everything, or you could say let’s do some things in steps now that make sense.”

He said he would expect the first reduction in the FEMPI cuts on a pro-rata basis with the public service to take place in the new year.

Additional supports for general practice

The Minister, in his recent response to the College statement on the under sixes, indicated that additional supports for general practice would be required to cope with extra demand. 

“We have already increased the number of training places; the other thing I would like to do is something about is practice equipment and practice support grants.”

The Minister said Dr Michael Barry of the National Centre for Pharmacoeconomics had prepared an initial paper for his Department on how grants for practice development might be linked to quality and standards in general practice and areas like rational prescribing. 

Minister Varadkar said this might be along the lines of the previous drug budgeting incentive scheme, but it would have important differences, citing the ‘perverse incentives’ that existed in the old scheme.

Access to diagnostics

On poor GP access to diagnostic facilities, the Minister mentioned the pilot project being organised in the west of Ireland where E700,000 worth of abdominal ultrasounds were being purchased for GPs’ patients, with access promised within five to 10 days. 

As to why, since the benefits of such schemes are self-evident, improved access cannot be rolled out nationally, Minister Varadkar said this is subject to available finance. 

“What I do think seems to work well is using the private sector, because the public hospitals are so swamped with their own work it’s easier to provide a dedicated resource on a tender, particularly for things like ultrasound.”

He says while access to plain film x-ray ‘isn’t bad’, access to ultrasound is patchy and access to CT is ‘terrible’.

On developing further initiatives, programmes and supports in primary care, the Minister said he would have liked to have seen things happening faster. 

“If the under sixes had come in two years ago, more could have been done.”

Under sixes and ethics

Asked if he agreed it was ethically unfair to provide free GP care to the children of better-off families at the expense of children and others on low to moderate incomes, the Minister said the first question he asks any GP who says that, is what their views were on the granting of full medical cards to everyone over 70, including very wealthy people, by the Fianna Fail/PD Government in 2002.

“When I ask that, the eyes tend to go down and people are embarrassed to answer it because of course, some of the people who are now arguing that the under sixes scheme is unethical, immoral and unfair were enormous financial beneficiaries of that (the over 70s scheme).”

He said there were similar logistical and ethical problems with means tests and sickness tests in deciding on eligibility for services. 

“When it comes to means tests, you always have people who are just a little bit over the threshold, and when you raise the threshold then you have a different group of people who are just above it.

“We had an expert group that tried to come up with a sickness test for medical cards and not only could they not decide who should get a medical card and who should not, they said to do so would be unethical and unfeasible. There is no perfect way to do this, but I would really question why people who are such big fans of means tests and sickness tests believe they are somehow morally right. 

“I am absolutely convinced that the only system that is ever going to be fair is one that provides universal coverage, but we can only do that in steps.”

Crisis in rural practice

The Minister says while there are difficulties in recruiting GPs in rural areas; “you do of course always hear about the vacancies that aren’t filled and you hear nothing when they are filled; so for example Ballyheigue was in the news because it hadn’t been filled; it has now since been filled and it was filled by giving the GP who is taking it over some support to develop the medical centre. Arrangements are being put in place around the country.

“I know it has been said that the rural practice allowance (RPA) has been taken away. That’s not the case. What does happen is areas cease to be rural. So if somebody took up a contract in the 1980s it was a rural area; then when they retire, the person who gets that contract may find the place is not the place it was in 1985; it’s no longer a rural area.”

He agreed that this does affect practice resources if the allowance is no longer available under those circumstances, but there had been no policy decision to take away the RPA. He said it had been agreed with the IMO that this was an issue that could be looked at.

“But I think we also have to potentially look at different models. Not just for rural practice funding, but on how we provide GP services in rural areas. The rural GP who’s willing to work seven days a week; I’m not sure any amount of money in the modern era would encourage people to work that way. People rightly have different expectations about work-life balance, so I think it’s a mistake to believe that if you increase the RPA or put in area-based payments that all of a sudden huge numbers of people will be queuing up to be single-handed GPs.”

Asked if the distance payments were likely to be restored, he said that was another matter for negotiation. 

“But I don’t think this is necessarily where the solution lies. It might make more sense to serve a rural area through a group arrangement.”

Free GP care for all?

Minister Varadkar cannot put a timeline on when GP care for the whole population will be rolled out, should the current Government be re-elected. 

“Firstly, that has to be done by negotiation; secondly, we need to see how the under sixes pans out; whether it really does significantly increase attendances, and as I’ve said I’m not particularly hung up on how we do the next phases. I’m open to suggestions, for example, on whether we prioritise chronic diseases first or that we increase the income limits first. But what I definitely want to do is to cover all children in the next term of the Government, if we do get one. I don’t think it’s right that children are means-tested on the basis of their parents’ income. We don’t do that for education, we don’t do it for child benefit, it’s only in health.”

He said when it comes to covering GP services for working adults, there are different options. “One option that could be explored, for example, is using the social insurance system, or existing private health insurance, or using the Universal Health Insurance system to refund GP fees for working adults. But again, that’s something that needs to be discussed.”

Universal Health Insurance

On UHI, the Minister says he realistically cannot predict at this stage the timeline for its roll-out, or what model will be used. “There are a lot of factors in play that effect timelines.”

Asked was he against the UHI model proposed by his predecessor, of private health insurance companies running such a scheme, Leo Varadkar said he was not opposed to this. “I just want to see the numbers; see how much it would cost people in terms of premiums, and I want to see evidence that it will bring about efficiencies. I also want to see how much would end up going to the profits of insurers, and in transactional costs, rather than into services.”