WE’VE ALL been there; you walk into the GP’s office, wait more than an hour for a three-minute appointment, and then walk out again up to €60 poorer. Or you know what’s wrong with you, but you have to shell out on doctor’s fees simply to get your hands on the prescription that will treat your ailment.
Maybe it’s the €20 the doctor charged you for sending an e-mail (which happened to me), the full-rate charges for each child, the difficulty in seeing your actual doctor instead of a locum or the fact that you have to pay to see the doctor first before being referred to an even more expensive consultant.
Even consumers who are perfectly satisfied with the standard of medical care they get from their local doctor are growing increasingly restive at the cost involved. Many of the costs of running a surgery, such as staff, heating and lighting, are falling in the current bout of deflation. So, the question goes, why aren’t fees falling in tandem?
Data on doctors’ fees is surprisingly sketchy given that two-thirds of the population, those not on medical cards, pay their own way. A recent online survey found fees ranged between €30 and €65 for a consultation, with the average around €50.
Private GP patients qualify for tax relief on their medical expenses, but only at the standard rate of tax of 20 per cent. While almost half the population has private health insurance, only a small proportion of subscribers are in a position to claim for GP expenses. Hospital AE departments used to provide a cheaper, public medicine alternative to the GP until charges were imposed and gradually increased to a prohibitive €100.
Effectively, this means that most of us are on our own when it comes to paying for primary medical care, and virtually all of this care is provided by the private sector. The only constraint on price is what the market can bear, and given that we’re talking about people’s health, the market will bear quite a lot, even in a recession.
CSO figures show “doctors’ fees” rising at almost three times the rate of inflation over the past decade. The divergence between medical inflation and other prices became particularly stark during the past year. There are no specific figures for GP inflation, but the Competition Authority says the general figures from the CSO give a reasonable indication of trends for these fees.
“Everyone has a tale of paying less for a doctor in France or Germany, but the systems in those countries are different,” says Carol Boate, director of advocacy with the Competition Authority. “It might cost €30 to see a GP in France, or nothing at all in the UK, but that’s not comparing like with like.”
Analysis of the data appears to show that cost deters Irish people from having their health checked out. Medical card holders, who get the service free, go to the doctor too often, researchers have found, while fee-paying patients don’t go often enough. The difference, after adjusting for various factors, is put at more than one extra visit a year. Another study found that one in five patients with a medical problem didn’t go to their GP due to cost.
Whether this makes any difference to people’s health is “difficult to say”, according to Anne Nolan of the ESRI. There is, however, tentative evidence that disability rates among older people dropped following the granting of medical cards to all over-70s (subsequently removed).
It isn’t just patients who are complaining about the cost and quality of the service. One Dublin GP believes the fees charged by many colleagues are extortionate and says some are more interested in throughput than their patients’ means.
“As a patient, you’re lucky if you get five minutes with them, but I don’t know if that’s a good service. I don’t know how any GP could see a person properly in less than 15 minutes – by the time you get them undressed and have listened to their issues, the time would be up. So what are you getting for your €60?”
Low-earners who fall sick are particularly hard hit by high fees, she says. “Someone fractures a hip or suffers some other ailment and within six weeks, they’re on disability cheques. But they need a cert on a weekly basis, so they have to pay €60 out of their €200 cheque each week to a doctor.” On top of this, a thoughtless GP might prescribe a painkiller costing €80, when a cheaper alternative is available for €10, she says.
The doctor is critical of the lack of innovation in the profession and even questions the quality of much GP care. “You’re basically talking about intelligent people who have become deskilled and refer all the time.”
For example, Irish GPs are less likely than foreign counterparts to do minor surgery or stitching, she says, and are more likely to do the work done by nurses in other countries.
The Irish Medical Organisation (IMO) said it couldn’t comment on the fees charged by its GP members for fear of infringing competition law. A spokeswoman pointed out that the IMO has in the past been raided twice by the Competition Authority.
While the system works well for once-off diagnoses of relatively simple ailments, it serves the consumer poorly when things get more complex. Many doctors will charge full fees each time for repeat visits by patients with recurring health conditions.
In some cases, this can amount to a “failure bonus”, where the GP doesn’t manage to clear the condition but gets financially rewarded for his lack of success. Ultimately, the patient may be referred to a consultant, and ends up with the bills for both GP and specialist.
Sometimes, the only reason for going to the GP is to get a renewed prescription or a sick cert. Practice varies from doctor to doctor, but it’s clear many GPs charge for the privilege of writing a prescription or a cert, irrespective of the level of examination that precedes the application of fountain pen to paper.
Others simply demand a consultation fee before they will write the prescription. A Dublin reader says her doctor charges €50 for a consultation, and €20 for a repeat prescription. As she needs a new prescription every six months, she pays €140 a year to have her blood pressure checked and get the necessary piece of paper. She wants to change GP, but can’t find one still taking patients.
Another frequent beef of consumers is the practice of charging full fees for children, and charging children separately when they attend with their parent. I’ve had the experience myself of attending a GP while minding a child, and making the mistake of asking him to look at the three year old. Despite getting out in under 10 minutes, I was hammered for €100.
Maybe I was lucky; one poster to ask aboutmoney.com records being charged €60 after a vaccination appointment even though his child was judged too feverish to be given a jab.
One of the drivers of high cost, identified by both the Competition Authority and the ESRI, is the shortage of GPs.
Ireland has two-thirds or less of the number of GPs found in other European countries, relative to size. Our GPs are ageing, more of them are women with shorter working lives, and more are working part-time.
In addition, as the Competition Authority points out, training is more structured than it used to be. “Once upon a time a GP was someone who hung up a sign after completing medical education, but now you have to spend four years in specialist training,” says Boate. Thus, the number of new GPs is linked to the number of training places available, but resources for these places is lacking; unusually, Boate points out, GPs are paid a full salary while apprenticed.
Continuity of care is a stated aim of primary health services, yet it remains as hard as ever to get out-of-hours treatment. The old model of the sole trader doctor making house calls is dying out, and plans to replace it with larger health centres operated by groups of doctors and other health professionals have been slow to reach fruition. In some of the waiting rooms I’ve had the privilege to, erm, wait in, it was clear that the biggest investment was the pile of five-year-old copies of Hello.
Another Dublin doctor says his profession has been slow to innovate but knows it can count on the loyalty of patients. “An annual fee rather than a per-visit fee would be a great idea, for example, and would give doctors greater cash flow.”
He believes GPs should get more business training before qualifying and will have no choice but to work together in partnerships. “Opening your surgery for a few hours a day doesn’t suit people and no one is interested in sole practice anymore.”
There’s little immediate prospect of relief for hard-pressed consumers with big medical bills. The doctor believes Government cuts in fees paid to GPs under the medical card scheme has made them “disinclined” to trim fees for private patients (on average, GPs were getting €64 per visit for medical card holders). The continuing shortage of GPs means the provision of primary healthcare will remain a sellers’ market.
IN THE DOCK: HOW DO YOU RATE YOUR GP?
‘OUR REGULAR GP is brilliant, always gives you time, is thoughtful, even makes sure to suggest generic drugs so you don’t get fleeced in the pharmacy. She charges €55 for about 15 minutes. Recently she was away and I brought my daughter to another GP, same €55 charge, but visit lasted less than three minutes, GP barely listened, daughter was pronounced to have a sore tummy and we were rushed out the door with a laxative. Ended up bringing her to regular GP the next day and it turned out the issue was one of stress, no physical problem. Total cost €110.
– CATHERINE
‘VISIT LAST year to my long-term family doctor to renew my pill prescription (they insisted I come for a blood pressure check). I arrive on time for appointment, wait 20 minutes, see the doctor. I explain why I’m there, then his office phone rings, he takes the call, apologises, then begins to write out my script. I say, “Should you not check my blood pressure?” “Oh since you’re here, yes.” Phone rings again, he answers and deals with it. Two minutes later I’m out the door, relieved of €65 for my five-minute consultation, two of which were spent on the phone. I haven’t been back since.
– CB
‘MY GP in Dublin 4 charges €70 per visit plus extras for blood tests, etc (€40 for bloods actually – not funny). When it came to making my annual claim from my health insurer for GP visits last year, they sent me a letter which basically said that my GP charges in excess of their average claims and therefore would not be refunding me the 50 per cent for each visit that my policy entitles me to.
– FIFLE
‘I WAS in France last year, and needed to visit the GP with my daughter. It was the standard visit, checking ears, throat, etc, and a fairly standard outcome – an ear infection, to be treated with an antibiotic. At the end, the doctor apologised and said as I was not a French citizen, he’d have to charge me as a private patient. He charged me €25. Here I pay €65. I accept that some costs in Ireland may be higher (although this was in a French holiday resort with very high property prices). But I can think of no other good or service that costs 160 per cent more in Ireland than France.
– GIUSEPPE
‘WHILE SERVICE from the eight-doctor practice I attend is adequate, I would contest that value is questionable for the following reasons: fees at €60 per visit have not decreased in the current climate. Even solicitors appear to have reduced fees! I consider that charging €15 for a six-month repeat prescription for medication I am on for life, and reviewed on an annual basis by my consultant, is extortionate. Incidentally this fee was increased by 50 per cent in 2009. No weekend or early morning/late evening service available, unlike my local dental practice which offers two mornings starting at 7.15am and two evenings running to 7.30pm.
– BRIAN
‘MY DOCTORS run a family practice and they are usually very good and give you lots of time. The fee for a visit is €45. I live in south Tipperary. If you need to go for further medication or another visit for the same issue, there is normally no charge.
– MARY
‘IFELL and cut my hand, went to the doctor and was told I’d have to go to the hospital to get stitched. “What? You’re a doctor, you stitch me. Two stitches later I was home, glad that I had stuck to my guns on that one, with such a minor injury I would’ve been in AE waiting for days. A friend of mine was mugged in Brussels and took a bang to the head, went to his local doctor, within two hours he’d had an X-ray, a scan, treatment for his cuts and bruises, a prescription filled and was home again – and it cost him nothing. Why does everything have to go to hospital? If most dentists can take X-rays in their office, why can’t Irish GPs?
– GAVIN
‘WHAT IS really frustrating for me is the overcrowding in my surgery and the lack of continuity. I’ll be given an appointment time for 4.30pm. I arrive at 4.20pm and let them know I’m there and wait an hour to be seen, usually by a locum because they haven’t gotten in a full-time replacement for the doctor who retired a couple of years back. In one instance, I was treated by a lovely doctor from South Africa. He was brilliant and took a lot of time with me and told me to come back in four weeks to see how I was progressing. Only, he wasn’t there four weeks later and they had another locum in.
– CAROLINE
GPS ARE very reluctant to order blood tests for you. I really can’t understand how a GP can give any patient, especially a small child or baby who can’t communicate how they are feeling, a quick once-over and declare a virus and nothing more sinister. For adults and children, bloods should be taken routinely.
– LAURA
‘MY GP is one in a million. When I presented at his surgery some years ago he drove me to the hospital himself as he realised I was very seriously ill. He and the other doctors in the surgery charge €30 for a short visit, €50 for a longer one and no charge for a return visit for the same problem.
I never pay for a repeat prescription. My consultant in Tallaght hospital has not raised his fee during the five years I have been attending there. I have huge admiration for all the doctors who have treated me.
– GEMMA
BY CONOR POPE
