National sections

The Health System in Ireland and the role of G.P.

Dr Anthony J Hynes, Head of the UEMO Irish Delegation

Economic indices and government  pay  policy
Ireland is a small country, an island on the periphery of Europe. The population of the Republic of Ireland is 3.7 million people. At the present time Ireland is doing economically well. Gross domestic product (GDP) is US$68.3 billion and GDP per head has increased to $18,620.The GDP growth for 1998 is predicted to be six per cent and inflation is 2.7 per cent. Unemployment is falling, interest rates are at their lowest for 20 years and are expected to fall by a further 1.5 per cent at the end of 1998.Ireland is set to join the first wave of Economic and Monetary Union (EMU) members. Optimists expect the 'Celtic Tiger' economy, with its growth rate of twice the European Union (EU) average, to bring Irish living standards even closer to our more prosperous European neighbours. Pessimists feel that there are storm clouds on the horizon, due to:

• the elimination of EU structural funds from 1999;

• further Common Agricultural Policy (CAP) reforms in line with the General Agreement on Tariffs and Trades (GATT) Mark II;

• the UK opting out of the first wave of EMU;

• poor control over Government spending (which has increased an average of eight per cent per annum since 1990);

• failure to eliminate the exchequer borrowing requirement in 'boom' times, and failure to reform the tax system despite a recent budget reduction of two per cent in the standard and top rates of tax.

However, consensus on economic policy is not under threat, since the latest national wage agreement between the social partners and the Government, 'Partnership 2000', is in place. Pay increases outside the agreed guidelines will not be possible.The health system in Ireland is funded primarily from general taxation and is publicly provided, with private healthcare playing a significant role. Public health expenditure in 1998 is predicted to cost IR£3.1 billion, an 11 per cent increase on 1997. This is approximately six per cent of GDP, while private healthcare expenditure is estimated at two per cent of GDP.The Department of Health has responsibility for the services provided by eight regional health boards (authorities). The Department's remit extends to public and public 'voluntary' hospitals whereby in future, public monies will be given to these hospitals via their local health board. There are n small number of purely private hospitals operating without the control or influence of the Department of Health. The Department of Health sets the annual health service budget, it reviews existing services and initiates proposals on new service developments, and it initiates regulatory and legislative changes. The eight regional health boards are responsible for service delivery in community care, general hospital care and special (psychiatric) hospital care.The health strategy policy document, 'Shaping a Healthier Future' (1994 — 1998) aims to enhance the health and quality of life of the population. Priority is given to preventive medicine, particularly plans to address the main contributors to premature- mortality such as smoking, alcohol abuse, drug abuse and poor nutrition. The Irish Medical Organisation (IMO) has called for a ban on tobacco advertising for many years and congratulates the European Commission, under Mr Flynn's Directorate (DGV), on their recent success with the Council of Ministers in ensuring a phasing out of tobacco advertising over the next three years. A National Breast Screening Programme is to be introduced on a phased basis from 1998. There are particular opportunities for general practitioners to have a pivotal role in the implementation of many of the specific targets laid out in the health strategy document.

Eligibility for medical services
The Department of Health divides the population into two categories for the provision of medical services:

Category I
People in Category 1 receive a medical card from the health board. There is a means test for this card based on the amount of income allowed and is revised every January. People whose income exceeds the normal guidelines may be given a medical card if the health board believes that they are unable to provide necessary medical care for themselves and their family. The services available to people in Category 1 are:

• general practitioner services;

• prescribed drugs and medicines;

• all inpaticnt public hospital services in public wards (including consultant services);

• dental, ophthalmic and aural services and appliances;

• a maternity and infant care service. This includes the service of a family doctor during pregnancy and family doctor service for mother and baby for up to six weeks after the birth;

• a maternity cash grant for each child born.

Category 2
For those who do not qualify for a medical card, they are automatically in Category 2 and are private patients but entitled to the following services:

• all inpaticnt public hospital services in public wards (including consultant services) subject to certain charges;

• outpatient public hospital services (including consultant services) subject to certain charges, but excluding dental and routine ophthalmic and aural services;

• a maternity and infant care service;

• Drug Refund Scheme/Drug Cost Subsidisation Scheme/Long-Term Illness Scheme.

Private medical insurance
Approximately 40 per cent of the population opts to take out private medical insurance, mainly for unexpected hospital treatments. Up to 1995, the state owned company the Voluntary Health Insurance Board (VHI) had a monopoly position. Under a new health insurance act, this monopoly position has been abolished. The only new player in the private medical insurance market is BUPA Ireland. Both companies are now selling their products on a community rating basis, ie, every member in the scheme pays the same premium regardless of risk, there is open enrolment, lifetime cover and a minimum scale of benefits. Essentially there is no scheme to cover general practitioners' (GP) services, as a patient cannot claim until they have attended their GP more than 20 times in one year. As the infrastructure and range of services provided in genera] practice expands, fees will increase and there is likely to be public demand for an agreed private medical insurance scheme to cover general practitioner services realistically.

Primary care
Healthcare at community or primary care level encompasses the General Medical Services Scheme (GMS): community nursing, maternity and infant care, dental, ophthalmology and aural services. Persons eligible under the GMS Scheme (category 1) benefit from a comprehensive family doctor service and prescription medicines which, in the opinion of their chosen doctor, are appropriate and necessary for their ongoing treatment. A choice of dentist schemes has recently been added to the range of health services for GMS eligible persons. Private patients (category 2) can benefit under the Drug Refund Scheme, the Drug Cost Subsidisation Scheme or Long-Term Illness Scheme for expensive medical items. In 1 996 there were 1,647 participating doctors in the GMS Scheme, 1,153 pharmacists and 963 dentists.

General practice
Thirty-six per cent of the population are covered under the GMS Scheme (1,286,813 people), and 64 per cent of the population attend as private patients. Under the GMS Scheme the majority of doctors are paid an annual capitation fee for each eligible person, the rate of pay being determined by the age/gender of the person and distance from their doctor of choice. A minority of doctors in the GMS Scheme are paid a fee per item of service, while all doctors in the Scheme can and do treat private patients. There are an estimated 600 doctors working as general practitioners in private practice only, as full-time locums, as assistants/associates to established practices, or in occupational medicine. Private patients pay their doctor a fee for consultation and additional fees for any investigative or surgical procedures. The GMS Scheme is a social security system paid out of general taxation. Private practice operates as a liberal system but is not financed by private medical insurance;the patients pay the doctor from their own resources, without reimbursement from any source. There are no community specialists competing with GPs at a community level. There is free access to specialists in their 'rooms', either on-site, in the hospitals, or out of the hospital, but as all specialists have hospital appointments (either public, private or both) any investigations or procedures are carried out on the hospital site. Some specialists promote direct contact from patients, but the majority encourage referral from a GP before they will see a patient. At this point in time there is no fee accruing for the GP briefing/debriefing functions in relation to referral to a specialist.

Irish Medical Organisation (IMO)
The IMO is the national medical association representing all doctors (specialists, general practitioners, junior hospital doctors, public health doctors, doctors in academia, the army and the pharmaceutical industry). The GP Committee of the IMO is independent of other craft groups, but reports to the IMO Council and abides by general policies of the IMO as decided at the annual general meeting. The GP Committee negotiates with any agency with a contractual relationship with general practitioners, and also seeks to give leadership in defining strategy and policy initiatives to influence Government planning on developing the potential of genera] practice.The threat of industrial action by the IMO general practitioners in 1992 secured a 17.5 per cent increase on all fees and allowances payable under the existing GMS capitation contract, as recommended by the arbitrator. Fees and allowances were also increased in line with the recommendations of the Programme for Economic and Social Progress. The GMS Development Fund was established with an investment of IR£12.5 million per annum, for the improvement of rostering and out-of-hours arrangements, maintenance and development grants, supplementary grants for secretaries and nurses, and other specific initiatives.Indicative drug budgets were introduced, with savings to be shared on an equal basis between the doctors and the health boards. The permanence of the 1992 agreement was secured in 1994, when the GMS Scheme was again reviewed with agreements to take effect from 1 January 1995.

The main features of the review agreement are that:

• the General Practice Unit of each health board should discuss with individual GPs the manner in which the General Practice Development Fund is being used by doctors, and should prepare a quarterly evaluation report;

• all parties agree to encourage GMS doctors to participate positively in the indicative drug budgeting scheme;

• dispensing fees paid to participating GPs under the GMS are superannuated subject to the provision that it does not set a precedent for other claims;

• new arrangements for consultation in relation to appointments to the GMS Scheme and the recruitment of partners and assistants with a view to partnership are agreed;

• GPs are granted entitlement to special leave subject to the approval of the Chief Executive Officer of the appropriate health board;

• study leave entitlements are increased from seven to ten days per year, the additional three days leave relating to particular service requirements as determined by the relevant health board;

• a General Practice Research and Education Fund is established;

• acknowledgement of infrastructure developments are a priority for the development of general practice, and that funding must continue to be available;

• there is improved liaison between General Practice Units and local representatives of the IMO and the ICGP;

• the concerns of doctors working in deprived urban/inner cityareas and remote rural areas are further considered. In April 1997 the IMO concluded an agreement with the Department of Health in relation to a number of general practitioner issues. Some of these issues represent landmark deals in terms of radically altering the arrangements that previously existed. The details of the agreement are as follows:

With effect from May 1 1997, out-of-hours fees will be paid in respect of necessary non-routine consultations carried out:outside the hours 9am to 6pm outside the hours 9am to 1pm all hours excluding consultations made during normal contracted surgery hours which are outside the above hours, and excluding consultations made as part of an overflow occurring in normal surgery hours.The health board will require third party verification of the time of the consultation. General practitioners will not vary their existing contracted surgery hours except by agreement with the health boards. The terms agreed under this item replace those in paragraph (iv) of the Form of Agreement dealing with out-of-hours payments and where more than one patient is seen in the course of such consultation, the fee payable for each additional patient is set out in the current fee-schedule as published by the General Medical Services (Payments) Board

Pension entitfements of former District Medical Officers (DMOs)
It was agreed that the IMO and the Department of Health would jointly submit a proposal to the Department of Finance for a substantial increase in the pension entitlements of former District Medical Officers

GP human resources
It was agreed that a review group would be set up to address the issue of GP human resource requirements. The group will comprise representatives from the Department and the IMO (in conjunction with the ICGP)

Family planning
In respect of certain items related to family planning, the following fees would be paid to suitably qualified doctors:Advice and fitting of a diaphragm IR£25.00 Counselling and fitting of an IUCD IR£40.00.The Department of Health agreed to undertake a review of family planning services (including cervical screening), and fees payable to general practitioners in respect of family planning services would be considered in light of the review

Maternity leave
It was agreed that the entitlement for maternity leave within the GMS Scheme would be extended to those GPs with lists of 100 or more, as opposed to the previous commencement point of 500

Banding levels
With effect from 1 January 1997, the banding levels for annual leave allowances and nursing/secretarial support have been revised. It was agreed that these allowances would be paid on a monthly basis, rather than quarterly as before.Since 1993, the credibility of GPs in relation to an exercise in reducing the escalating GMS. Drugs Bill has been demonstrated. As a voluntary exercise, each GMS doctor is given an individual drug target for the year. A majority of doctors make savings. The budget and targets are negotiated by the IMO in such a way that there are no ethical challenges for doctors, yet an incentive for appropriate and cost-effective prescribing is provided. The incentive provides an investment fund of £10 million per annum for structural and infrastructure developments in GMS practices. This fund is administered through a new entity, the GP Unit in each health board region; Each GP Unit has a group of practising doctors contracted to advise on how the Unit can best facilitate, support and develop general practice in their area. Since their creation in 1993, they have been supported by the IMO and are broadly accepted as being a positive influence in bringing about improvements in general practice.The IMO is committed to convincing the Government, the Department of Health and the public that a general practitioner based medical care system will deliver competent cost-effective clinical care to patients. Up till now over 60 per cent the health budget was allocated to high cost medical care in hospitals and institutions, with ten per cent going to general medical services, including drug costs. The task in current negotiations will be to secure sufficient resources to ensure Irish general practice will, in future, be architecturally visible and competently staffed, so that any patient requiring medical attention will be convinced their needs will be met, in the first instance, by a general practitioner/family doctor. That doctor will be an increasingly competent, trained physician, committed to personal care and continuity of care to individuals and families. They will have the knowledge and the skills to diagnose, investigate, treat or refer as appropriate. They will also coordinate medical treatment for patients between the hospital sector and community care services

The Irish College of General Practitioners (ICGP)
The academic interests of general practitioners are represented by the Irish College of General Practitioners. There is a close and harmonious relationship between the IMO and the College in relation to general practitioner interests. Dialogue and agreement on priorities have obvious advantages before negotiation with Government or other agencies begin. The IMO welcomes the formation of the European Society of General Practice/Family Medicine and is confident, given that Ireland is hosting the Presidency of UEMO, that at a European level the best interests of general practice will be served by having just two bodies speaking with authority for general practice.The College has been in existence since March 1984, and all of the original objectives have been achieved. General practice is a recognised speciality; a continuing medical education (CME) network of 28 tutors and 130 small groups has been nationally established, with a 65-70 per cent participation rate; GP training programmes have been established in all health board areas; departments of general practice have now been established in all medical schools; a comprehensive range of skills courses is available and the management programme 'General Practice — a business enterprise' has been successfully launched, including the 'Management Services/Information Unit'. The MICGP examination is the recognised entry to general practice and is internationally recognised; the College is a key player in the healthcare policy process and 64 publications and policy statements have been issued; the College journal, 'Forum', continues to thrive, with membership at an all time high of 2611; the College international standing is acknowledged with the hosting of the World Conference for General Practice in Dublin in June 1998 (WONCA).There is constant change taking place in Irish general practice, with ever greater responsibility and demand being placed on general practitioners. The aspirations of general practitioners are very positive, as evidenced by the National GP Survey of 1996, the first reports of which have been recently published.To meet these changes and to provide the necessary support to members, the College itself must increase its professionalism and capacity. Towards this end the 'Postgraduate Resource Centre' was established as a unit of the College with a full-time director. The Centre will have direct financial support from the Department of Health.In total there are 22 salaried personnel working with the College, including 12 staff members, five Skills Fellows, four Quality Assurance Research Fellows and the Director of the Quality in Practice Programme

Basic medical training
There are five medical schools in the Republic of Ireland. There are now five Chairs of General Practice in each College. Recognising that 50 per cent of medical graduates have a desire to enter general practice, the undergraduate curriculum still fails to reflect this fact. The Medical Council has prepared a discussion document on medical education, completed assessments visits to the five medical schools, prepared interim reports indicating recommendations for each school, and planned a series of further visits over the next two years

Specific training in general practice
There are 55 places available per year in specific training schemes in general practice. All training schemes are a minimum of three years duration (one is of four years). Specific training in general practice begins after the end point of basic medical training. All schemes incorporate day release programmes during the hospital component of training. Training 'on-site' in general practice is commonly one year, but efforts are being made to increase this period to 18 months in line with the UEMO Consensus Document on Specific Training for General Practice and subsequent Advisory Committee on Medical Training (ACMT) recommendations. In future the training may increase to five years, to harmonise with other specialist training. In the meantime concentration will be on content not duration, with the aim of allowing a graduate to work as a competent independent specialist in general practice

Those doctors working in the GMS Scheme are entitled to one weeks paid study leave per year. The ICGP approves suitable courses, seminars, study days, skills courses and small group learning meetings. There is a CME tutor in each College faculty, usually the Education Officer on the Faculty Board. Small group CME has proven itself to be the most popular, with participants receiving favourable national and international comment. Indeed the 'model' has been exported to a number of countries

Quality assurance
Many GPs agree individual or group 'quality pacts' subsequent to a particular topic discussion at small group CME meetings. There is no State remuneration for any quality assurance work.In December 1995 a new general practitioner based National Childhood Immunisation Scheme was introduced. There have been many obstacles to the successful operation of the new Scheme, not least the non-cooperation of district nurses and organisational and Information Technology (IT) difficulties at health board level. This Scheme is vital for the future involvement and resourcing of national public health schemes with genera] practitioner participation, as the outcome is measurable and success/failure responsibility can be assigned

Specialist registration
The Minister for Health gave consent to the creation of specialist registration from 1 January 1997 and this facility is now available to all eligible doctors. The Medical Council is in the process of recording the applications. The Council has received support from all the specialist advisory bodies in establishing criteria and procedures to deal with these applications. Specialist registration is a voluntary, not an obligatory procedure, but it seems likely that employers will increasingly seek evidence of specialist registration from candidates for career posts

Workload and workforce
There are 1,647 doctors in the GMS Scheme. There are 600 doctors working in private practice. The current annual requirement of new entrants to the existing GMS Scheme to cover death, retirement and service expansion is only 25 to 30 per annum. There are 55 graduates from the specific training schemes annually. The only method of entry to the GMS Scheme is by interview for an advertised post, or as an 'Assistant with a View'. This is now proving unacceptable to the excess 25 to 30 specifically trained doctors annually coming off the training schemes who do not succeed in getting a GMS position in a location suitable to them, usually where they have set up in private practice. This annual excess of suitably qualified doctors are seeking an 'open access' system to GMS posts.The IMO's position is that if such were allowed and accepted, there would be a multiplicity of smaller lists (current average GMS is 720 patients). This would have a depressant effect on average GMS incomes and would lead to a lack of opportunity for ordered development in genera] practice. An 'open entry' system into the GMS could only be considered if GMS eligibility was extended and its introduction was part of an overall workforce plan for general practice. This plan would take into account the viability of practices and the planned distribution of lists, while maintaining the essential element of choice for the patient. An 'open-entry' system would have to take into account the important question of the number of medical school graduates and the number of specifically trained graduates to be produced each year — keeping in mind the lack of European consensus on strict 'numerous clauses' in other Member States.The general practitioner in Ireland is regarded as the doctor a patient sees in the first instance for medical treatment and advice. The GP treats individuals and their families in context and provides continuity of care. The GP is increasingly moving from treating acute episodic illnesses to more active management of many chronic illnesses. The recent National Survey 1996 showed the high workload the average doctor carries. This workload is steadily increasing. This issue of increasing workload and future workforce planning must go hand in hand. General practice is now becoming architecturally visible, the staffing and equipment levels are improving, but the resourcing (between private and state) is still inadequate to provide a modern competent service. The lack of full patient registration is hindering progress, especially any proposed National Cancer Screening Programmes. The skills mix required will put intolerable pressure on single handed doctors practising alone. The provision of an (increasingly demanding) out-of-hours service after a hard days work has become an unacceptable strain for many. New working methods will need to be piloted to alleviate this strain. For those without access to 'doctor on call' services, the United Kingdom (UK) model of cooperatives, providing out of hour cover from a central base with agreed community guidelines for home visits, may have some benefit for many rural doctors. Others may be happy to continue with rota arrangements.