SECOND OPINION: It's time for a debate about our general practice system, argues Dr Susan Smith
Standing in the school yard recently, one of the other mothers mentioned to me that she had spent about €500 on GP consultation fees and prescriptions in the previous four months for her 16-month-old daughter who has recurrent ear infections and a persistent wheezy cough.
She seemed resigned to this though not impressed with a system where she has to pay to bring her child back to be checked again in 10 days' time to see if her ears are better.
She is probably relatively well off and well above the GMS threshold but this still represents significant unpredictable financial outlay.
I suspect most GPs are familiar with the feeling of discomfort when we realise that the patient we want to review probably can't really afford to come back again and yet, the argument goes, how will GPs run their practices without fees?
I have worked as a GP in three systems with different approaches to financing general practice care. The NHS in the UK has a capitation system in which GPs are paid per patient per year and all citizens are entitled to register with a GP and receive free care.
In Australia GPs are paid a fee every time they see a patient with payments coming from the government.
In Ireland, we have a mixture of a capitation payment system for the poorest 25 per cent of the population (the GMS eligible) and a fee per item payment system for the better off, though the fees are paid by patients themselves, albeit with the prospect of tax relief once they have spent over a certain amount per year.
I have been becoming increasingly uncomfortable working in this system, which is essentially inequitable and encourages GPs to treat patients differently depending on how they are paid, particularly in relation to asking patients to return for check-ups of blood pressure, etc.
There is compelling international evidence that user fees, even small co-payments, deter patients from seeing their doctor.
Consultation fees mitigate against curative care for those with financial difficulties and preventive care for all but the most forward thinking and financially well off who are prepared to pay to avoid sitting in an outpatient clinic where they can have their condition managed free of charge.
Is this the type of general practice system we all really want? Is it the type of system the graduates of our training schemes will want to work in? What are the forces that are propping it up and why is there no debate about radical reform of GP payment systems?
I want to work as a GP in a system in which:
everyone has the same access to me, access based on need and not ability to pay;
I have a definite list of patients for whom I am responsible;
patients have a choice of GP and GPs have the right to ask them to find another GP if they feel the relationship isn't productive;
I can spend at least 15 to 20 minutes with patients rather than eight to 10 as the evidence and my experience indicates that longer consultations are associated with improved quality of care and higher patient satisfaction;
my patients have access to reasonable 24-hour cover, provided by trained GPs in co-operative type arrangements with 24-hour general practice clinics in urban areas and a transport system to bring patients to such clinics if they can't get there themselves;
I can work with other primary care professionals as part of a team, particularly practice nurses and public health nurses though ideally also with physiotherapists, occupational therapists, speech therapists, pharmacists and social workers;
I can access specialist tests appropriately and specialist opinions readily when needed. I would also value real feedback from specialists about patients I refer to them for an opinion;
I am reasonably remunerated, salary is fine to me though I want to retain clinical independence;
I would prefer to work with GP colleagues than be single-handed though I would choose my colleagues with care.
Our Government now focuses on primary care rather than general practice and I welcome this but I wonder what other primary care professionals feel about fees.
For example, do community physiotherapists have problems with the current system which effectively excludes all poorer people with back pain from physiotherapy treatments unless they are lucky enough to live in a region where there is a community physiotherapy service for such problems or they can access it through specialist hospital clinic?
I think it is a ridiculous waste of specialist resources to have to access multidisciplinary skills in this way for our patients.
From talking to other GPs I think I am not alone in feeling there is a need for radical reform of the whole healthcare system but perhaps it is time for us to focus on our own services.
There is a genuine concern that we will be inundated if all patients are entitled to free GP care.
Experience in other countries of changing to free general practice care was associated with increased visit frequency but mainly in groups such as women and the elderly who had previously been deterred from seeking appropriate care as they could not afford the fees that applied.
Surely an increase in appropriate visits should be welcomed as long as it is adequately resourced. In the NHS, access to GPs is free but waiting times are longer.
That system seems fairer to me as it is possible to run emergency clinics on a daily basis to see those who genuinely need same-day care.
I wouldn't expect to ring my hairdresser and automatically get an appointment to have my hair cut on that day or the next.
I think we urgently need to debate our general practice payment system and develop a model that ensures high quality care, treats GPs and the patient fairly and allows the realisation of the full curative and preventive potential of general practice in Ireland.