Sunday Independent Money - April 27, 2014

Posted by Jill Kerby on April 27 2014 @ 09:00


As the row heats up between the government and general practitioners about the provision of free GP care for the under-sixes, parents will be forgiven for wondering exactly how much they will have to pay if their child needs medical attention from this summer.

The Health (General Practitioners Service) Bill will be passed in the next couple of months by the Oireachtas, the government has said, and free-GP care will then be available to the nation’s 420,000 under-sixes. Meanwhile, surveys by the family doctor’s professional organisations claim they will not accept the revised draft contract. 

Those who do not sign, warned Minister of State for Primary Care, Alex White recently, could lose their existing general medical service (GMS) roll of under six patients.

If that happens, all parents will have to find €50 - €60 to pay for their child’s GP visit.

This isn’t a good start for the ‘talks about talks’ expected to get underway shortly between the minister and doctors, though all sides seem to agree that free primary care for this mainly healthy age group is a good idea and should be affordable since most children are healthy and shouldn’t be a drain on current HSE finances. 

Out of an annual HSE budget in excess of €13 billion, just 3% of it now goes to family doctors. Existing child medical card-holders account for just €28m of that vast budget and the Department of Health estimates that just €37 million is required to fund acute and chronic care for all under-sixes.

However, it is this definition of care that is behind much of the GP protest about the revised contract.

The €43 per child per annum fee that GP’s currently receive from the HSE is supposed to cover the cost of acute care only, that is, visits and treatment for more serious illnesses or condition, not the usual seasonal colds and flu viruses, bumps, bruises and cuts. Family doctors say that single fee covers every visit, no matter how frequent or trivial.

The irony is that while 97% of the members of the National Association of General Practitioners have voted against this draft contract (in which a higher annual fee of c€70-€75 has been suggested) they say they would support caring for all under-sixes under a free medical card system if they had the proper resources.

Too many parents, they say, postpone bringing children who are genuinely unwell and need urgent treatment to their surgery until the last minute because of the cost of the fee.

The revised contract addresses the cost disincentive but will result in too many extra consultations that the average practice will not be able to handle. The result will be less time to treat patients who really need their attention, like the chronically ill and especially the elderly.

GP’s have already seen a 38% reduction from their share of the HSE budget in recent years amounting to €160 million, yet they conduct 95% of all medical consultations with no delay.  In Northern Ireland and the UK, where GP consultations are free, they see about a third more patients. (GPs get 8% of the NHS budget in Britain, which they say is also “woefully” inadequate.)

Last week the HSE figures on how long patients are waiting to see specialist consultants showed that children are faring particularly badly: by the end of January 2014, 1,464 had been in the queue for a year, up from 1,282 in December.

The new under-sixes payment to GP’s is expected to be approximately €74 per child per annum.  Some surveys in places like Northern Ireland and the UK where all family doctor visits are free, but access is usually by appointment, except for emergencies, the average number of child consultations increases by about a third.

Meanwhile, here in Ireland, the over-70s with gross retirement incomes of €500 per week or €26,000 per annum or €900 per week for a pensioner couple. Or €46,800 per annum still automatically qualify for a full medical card.

Before parents condemn the GP’s for resisting this new contract, they should know that there is already a shortage of family doctors. One in eight are aged 64 and emigration by newly qualified doctors and general practitioners is the highest for decades, according to the Irish Medical Organisation, which is holding its annual conference this weekend.

If the resource problems are not addressed, it said, the revised contract will hasten the retirement of many older GP’s and discourage young doctors from taking their places.

Caught in the firing line between the state and doctors are children and parents who may have to a new, participating GP if a deal can’t be worked out and their own doctor leaves the GMS scheme. 

Meanwhile, parents to may have to keep doling out €50 or €60 fee a visit should review the outpatient benefits offered by their private health insurance policy, if they still have one.

Families that have already dropped their cover might want to investigate cash health plans like HSF.ie (Hospital Saturday Fund) in which cash payments are made towards GP and other out-patient visits in exchange for a single family premium.

Working parents without any insurance cover or medical card should always keep their receipts and claim back the standard rate tax relief from the Revenue for their healthcare expenses.

With compulsory universal health insurance payments to be introduced from 2019, in which primary care will be a pillar benefit, this funding row could be just the first of many such confrontations.




Free healthcare for children is standard practice in Britain and many other European countries. It was also the starting point for the creation of Canada’s Medicare system back in the 1940s.

Today, all Canadians receive free primary care from family doctors who increasingly work within teams of practitioners in neighbourhood clinics.  Once they fulfil their time and residency qualifications, the 10,000 young Irish who are now setting off for Canada with their two year working visas will no longer have to pay to see the GP, or receive other primary care services.

Even when I was a child in Canada in the 1960s and ‘70s, the Canadian family doctor was paid per patient visit by the provincial health authority. 

All GP’s operate as private practitioners and run their own individual practices or health clinics as private businesses. They bill the province for a range of qualifying treatments and services, which are subject to regular contractual negotiation.

It can sometimes be difficult to find a GP that will add you to their patient lists, and in poorer maritime provinces like Newfoundland, but also in some deprived urban areas in richer provinces, waiting lists can be long and patients sometimes have no choice but to resort to hospital accident and emergency departments for treatment.

Unless it is an emergency, often determined over the phone by the practice nurse, Canadians have to make appointments to see their GP. Family members who live Montreal, Ottawa and Toronto tell me that you can usually expect to be seen within 48 hours if you are sick. (By then, a nephew with young children told me, “you might have already resorted to visiting the pharmacist for his opinion.” Non-hospital prescriptions are not covered by the Medicare system.)

Appointments for non-acute consultations like check-ups, dermatological treatments, general aches and pains can take weeks or even months.

An ageing Canadian population, especially amongst the more affluent baby boomer, means that queues for elective procedures like hip and other joint replacements, and common optical and dental procedures have grown very large.

Those who can afford to buy supplementary risk-rated private health insurance to bypass the Medicare system and even to secure semi-private and private accommodation in public hospitals, once you get in.

Many more private clinics and hospitals have also sprung up across Canada in the last 20 years, but there is no public funding available and only cash buyers or the well-insured have access. There is no queue jumping over the public hospital waiting lists.

The Canadian public health system is under considerable pressure from its ageing population and rich provinces like Alberta and British Columbia object to the Medicare transfer payments they make to the poorer ones’ schemes.

Yet most Canadians claim to be satisfied with how the free primary care system.  Family doctors (and consultants), who are self-employed are also mainly satisfied with their status and have no desire to be directly employed by the state.

The primary Medicare system in Canada, they say, is relatively efficient and relatively cost effective because it avoids using insurance companies as middle-men.

Which, ironically, is exactly what is being proposed for currently private, but contracted Irish family doctor’s services from 2019 when the new risk-rated universal health insurance system is supposed to begin.

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