independent

Friday 18 April 2014

If you're holding your breath for promised health initiatives, don't

Free GP care and Universal Health Insurance are unlikely to arrive anytime soon

Free GP care is planned for children under six. Picture posed/THINKSTOCK
Free GP care is planned for children under six. Picture posed/THINKSTOCK

We have entered familiar territory with the controversies over Universal Health Insurance (UHI) and free GP care for the under-sixes. We are now, as we so often are, not on the edge of a brave new world, but in the land of political promises, where the fulfilment of a promise is the main aim – the introduction of some fairness, efficiency and quality in our health service is a mere by-product.

It all started so well. 'Free' GP care sounds like something good – who could be against something that would ease the weekly financial burden on families? Universal Health Insurance sounds wonderful too – the first real measure that attempts to provide healthcare on an equal basis to everyone, or so it would seem from the terminology.

The reality, of course, is much different.

Taking the first item of free GP care first, it is important to remember that there is no such thing as 'free' GP care. All that means is that you won't pay for the service when you use it. But you will pay. You will have to. GPs, after all, need to make a living. And while the Department of Health can cut back on their fees and resources, ultimately they can only cut back so much before GPs start leaving this country and leaving us in an even worse state. So somebody has to pay, sometime, and that someone is you.

While the Health Minister has been a strong proponent of the concept of free GP care – starting with the under-sixes – GPs have been underwhelmed. Various surveys have shown that only a tiny percentage will sign up for the contract to provide it, and even if there were a radical change in GP opinion, it would leave the minister a long way short of ever being able to introduce the measure.

There are many reasons for this: GPs have already lost a lot of their income in Financial Emergency Measures in the Public Interest Act (FEMPI) cuts in the last five years – they are not about to take on even more work without consultation and compensation. And despite the restrictions on their ability to negotiate over fees (and there is a current case in the High Court taken by the Irish Medical Organisation fighting this issue), they still effectively determine whether or not such schemes are practical, since they will be the ones doing the work.

But now this issue, like many other health issues, has become politicised. Minister Reilly is under pressure from his Cabinet colleagues to deliver 'free' GP care, and free GP care for the under-sixes is the first part of that. If he doesn't have some kind of free GP care in place before the next election (or Cabinet reshuffle), it will be the end of his career as Health Minister.

It would also inflict a potentially fatal wound on the Fine Gael party in electoral terms. Fine Gael promised free GP care within one term of office, but that was a mere step on the way to that great Nirvana of Universal Health Insurance (UHI).

If the free GP care hasn't happened by the election, Fine Gael will no longer be able to claim with any credibility that UHI is happening any time soon.

And that would be catastrophic for Fine Gael at election time. So Reilly must plough on through the stones and the rocks and present something that looks a little like what was promised, or blame the doctors. Of course, it doesn't have to be like that at all.

Reilly could – with a bit of imaginative thinking – deliver a solution that provides cheaper GP care quite easily. It wouldn't indemnify him from attacks from his political opponents that he failed to produce 'free' GP care, but it would be helpful to people, which unfortunately isn't the main goal here.

It's possible to get a reduction now on medical, optical and dental bills by joining a cash plan refund scheme that for a fixed monthly fee gives a discount on health bills. At least one plan in Ireland offers a GP telephone service (or webcam within certain hours) – which costs €10.25 a month. That's €123 per family per year.

Now we know that there are approximately 420,000 children out there who would benefit from the under-sixes scheme as proposed. Let's assume the worst and say that, on average, two of these children are in the same family. 210,000 families at a rate of €123 per family is just short of €26m – €11m less than it is proposed to spend on a scheme that isn't going to work. If the Government were simply to buy a health cash plan for people with children under six, they could provide cheaper care tomorrow, and be sure it was going to happen.

The families in question would also get refunds on all their GP visits – whether it's their children under six, their children over six (up to 21) or themselves. The higher the premium, the more they get back.

This solution works fine for the doctors. Because people are still paying the same rate upfront, there would be no increase in visits. In any case, hypochondriacs and inveterate visitors would have the phone service or webcam every time the baby coughs (medical fact: babies have been known to cough as many as five times without dying). And the GP still gets paid as he or she did previously.

It works for the patient because although they don't have 'free GP care', they at least have some help with their health bills, and they can have even more if they choose to spend more on a premium above the Government contribution.

It just doesn't work for the Government, because there is no political kudos in providing actual real help that can't be worked into election slogans such as 'free GP care'. Employers could get in on this act too. Especially ones that have high rates of absenteeism, like, eh, the Health Service Executive.

Employers offering such help to their employees would know that their employee could get a medical opinion on the phone or on the web, and they don't need an hour off to see a doctor. A doctor, by the way, who will feel no pressure to recommend a day off because the patient is also a customer who may not come back if their doctor doesn't give out enough 'off' days.

But if you think that free GP care is dead in the water, UHI is a concrete hull that has sunk to the bottom and will not be refloated. And here's why. If you are reluctant to queue for your GP because his surgery is busy dealing with the extra four million visits brought about by free GP care for the under-sixes, then you'll surely baulk at paying your health insurance as before, but having to wait like public patients now have to wait for services.

When the rate of private insurance in Ireland was at 51 per cent, it was a tough ask to persuade people to pay their insurance just to get the Irish public health service. But what was envisaged was that UHI would cover only basic stuff – the bare essentials – and everybody (including those who got it for free) would have to pay more for the 'extras'. Sometimes that's a private room, sometimes it's just getting to see the consultant without having to wait for years.

But now that the rate is 45 per cent and falling at a rapid pace, persuading middle Ireland to give up its preferential treatment for some bureaucrat's definition of equality is going to be impossible.

And we know that in middle Ireland, the part of it that cares the most is the older part. They are the ones who paid into private insurance for years and now they will be expected to wait for a service (for which they have already paid) the same as everyone else. Older people will simply not do this. They will carry Reilly out of Hawkins House and hang him on Poolbeg Street first.

Forget that the costs will skyrocket and we can't afford that either. Forget that quangos will be filled to the brim with incompetent political hacks and others seeking the big salaries that only the health service can give to otherwise useless people. Forget that a two-tier service will be replaced by a more expensive two- or three-tier service. UHI won't work without an efficient, competent and well-resourced health service and we all know that's not happening anytime soon.

So what will happen? If Minister Reilly cannot deliver anything other than promises of a better health service sometime in 2019, he will be replaced. The plan will be quietly shelved and we will be given a new and shiny document that will promise something else... in the future. Recently Reilly referred yet again to the problems in the HSE – a HSE, he said, which Micheal Martin had set up.

So now you know. It's all Micheal Martin's fault. Wait around long enough and there will come a day when some other minister will say it's all James Reilly's fault. The ministers come and go. The health service stays the same.

Sunday Independent

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