A way to break the row over doctor-only medical cards is possible but it will not solve all GP problems, writes Martin Wall
Last Thursday the Tánaiste and Minister for Health Mary Harney instructed her officials to begin looking at alternatives for improving the access of lower income families to GP services in the wake of the latest delays to the Government's plans for the introduction of doctor-only medical cards.
The alternative under consideration will involve some form of scheme by which the State would meet the cost - either through a voucher system, an advance payment or post-visit reimbursement - of seeing the doctor privately.
While such a scheme could be very complicated to operate, it could prove popular and get the Government off the hook of meeting its commitment to providing more people with free GP services while by-passing the current difficulties with the Irish Medical Organisation.
However, it would be wrong to think that such a move would alieviate the structural problems affecting the overall medical card scheme.
The general medical service (GMS) which includes the medical card scheme, is undoubtedly one of the more successful elements of the Irish health service.
The medical card scheme operates on a one tier basis. Private and public patients sit side by side in the waiting room. There is no institutionalised queue jumping.
But there are undoubtedly problems, both structural and in terms of industrial relations, which in time could undermine the entire service if left unchecked.
The Government has a blueprint for the development of the sector, the Primary Care strategy, which was widely welcomed by all sides on its publication in 2001.
This would involve the development of a network of primary care teams where doctors and other health care professionals would work together under one roof. The problem is that the Department of Health does not have the money to meet the €1 billion-plus bill to implement the strategy. The Tánaiste has indicated that the private sector will have to be encouraged to invest. However, tax breaks promised in this area last year by the former minister for health Micheál Martin never materialised.
There is also a growing manpower problem in general practice and parts of the State are already experiencing difficulties in attracting GPs to work there. If not tackled the era of significant waiting lists for a GP appointment may not be far away.
However, if anything, the rows over the introduction of the doctor-only cards and last week's breakdown of talks at the Labour Relations Commission highlight the deep mistrust that now exists between GPs and health service management.
Ironically, the IMO initially welcomed the introduction of the doctor-only cards as it would improve access to services for thousands of people just above the income threshold for conventional medical cards.
This problem has become particularly acute as rising employment and income levels have pushed around 100,000 people outside the scope of the free medical scheme.
But the introduction of the measure soon became emeshed in a row over a parallel benchmarking scheme and general pay round increases.
GPs were initially promised a benchmarking scheme and a chairman to conduct this exercise was appointed only for this offer to be withdrawn. The Department of Health also refused to pay GPs a number of increases due under general pay rounds.
The Government's determination to claw back €8.4 million in over-payments made to GPs for patients who were either dead or otherwise ineligible also poisoned the atmosphere.
The GPs claimed that they themselves were owed millions by the State in underpayments for looking after some categories of patients - a claim which new official analysis seems to have vindicated to a degree. The Secretary General of the Department of Health Michael Scanlan told the Dáil Public Accounts Committee in May that underpayments of €1.8 million had been identified and that this was expected to "increase significantly" when further research was finalised.
From the Government perspective it is clear that it is concerned at the soaring cost of the general medical services scheme and the value for money that is being provided.
In a presentation to the Oireachtas Committee on Health and Children last May the Tánaiste revealed that amount of money spent on the general practitioner component of the schemes (not necessarily to doctors themselves in income) increased from €158 million in 1998 to €300 million in 2004. In addition, the recent deal on the doctor-only cards, which is now on hold, would increase this bill by a further $93 million.
The Tánaiste told the committee that if the cost of the GP services had doubled at a time when the number of patients covered by the medical card scheme had reduced by 100,000 then in the future she would want to see "better results".
Apart from GP services, the Government is also concerned at the rapid increase in the cost of drugs which has risen by 212 per cent to €1.047 billion in the years from 1997 to 2003.
Overall all sides believe that the way forward is to wipe the slate clean and start again with a whole new contract governing the provision of services by GPs to the State.
The Tánaiste has made clear that she wants to expand the level of services provided to public patients.
"There are more procedures that general practitioners can do, one of which is cervical screening. The immunisation programme, in which we have very poor participation rates here, should be examined also. There are many issues that we need to discuss with each other with a view to having a greater role for the general practitioner, who is the most important player in the healthcare system in terms of interfacing with patients on a much more frequent basis.
"Follow-up care and managing chronic illness in the community and so on is very much a role for general practitioners," she told the Oireachtas Committee in May.
The Government will also want some form of new controls on drug prescribing with a greater role for cheaper generic drugs.
For doctors, the priorities will be the implementation of structured investment programme, along the lines of the strategy.
A review of pay and conditions to take account of new workload pressures, such as dealing with increased numbers of asylum-seekers, will also have to be addressed.
However, given the mistrust and bad feeling that exists at present these negotiations are likely to prove anything but simple and straightforward. A new initiative to get around the problem of the doctor-only cards could be workable but it will not solve all the outstanding problems in the general practitioner service.