Speech by Minister White at the IMO Annual Conference

1. Introduction

May I begin by thanking you for your invitation to address this National GP Meeting, taking place as part of the annual conference of the Irish Medical Organisation. I have met with a quite a number of individual General Practitioners in recent months, in different parts of the country, but I value enormously this unique opportunity to meet with you collectively – as the primary national representative body of General Practitioners in Ireland.

2. Universal Primary Care

The extension of GP care without fees to the entire population on a phased basis is a key commitment of this Government.

It is beyond dispute that the orientation of health systems towards primary health care, with general practice at its core, is essential if we are to deliver better population outcomes, improved equity, access, continuity of care and lower cost.

Ireland is the only EU health system that does not offer universal coverage for primary care. If we are serious about shifting resources and attention to this sector – as I believe we must – then we will have to remove the barrier of fees for GP attendance.

A decision whether to see a doctor should never be a commercial or a financial dilemma – not for any citizen.

As you know, the Government is committed to a universal GP service, with the first interim phase to cover all children under six years of age. The decision to start with this age cohort is in accordance with the recommendations of the Right from the Start Report of the Expert Advisory Group on the Early Years Strategy.

We are also following the lead given by the recently published report Brighter Outcomes, Brighter Futures: The National Policy Framework for Children and Young People, 2014 – 2020.

This Framework signals a shift in policy toward earlier intervention, and ensuring the provision of quality Early Years services and interventions, aimed at promoting best outcomes for children, and disrupting the emergence of poor outcomes.

This can be achieved through continuing to raise the quality of early years care and education, through introducing a second free pre-school year subject to resources becoming available, and through the provision of free GP care for those aged 5 years and under.

I do not believe that anyone will dispute the fact that children are a priority health group. This is already reflected in the provision of universal screening and surveillance services for young children.

Access to GP services will increase the likelihood of childhood conditions being identified earlier and being addressed more effectively. As the 2012 IMO Position Paper on Child Health notes, ensuring that children have the healthiest start in life provides the basis for good health in adulthood.

In this regard I would like to acknowledge and express my appreciation for the fact that the Irish Medical Organisation is supportive of Government policy to introduce GP care free at the point of access, though you have made it clear that this is conditional on the provision of adequate resources, and full and meaningful negotiations with the IMO. 

3. Health (General Practitioner Service) Bill 2014

The implementation of free GP care requires primary legislation, and as you know the Health (General Practitioner Service) Bill 2014 was published earlier this week.

The key features of this Bill are as follows:

–          it provides an entitlement for all children aged under 6 to a GP service without fees;

–          it removes the need for children aged under 6 to have a GMS medical card or GP visit card in order to qualify for a GP service;

–          it provides that the HSE may enter a contract with GPs for the provision of this service to children; and

–          it provides that the Minister may set the rates of fees payable to GPs for this service, though requiring that the Minister must  follow a set process before doing so.

It is intended to introduce the Bill in the Oireachtas during May, with a view to enactment by July.

Some surprise was expressed last week at the fact that all children aged under 6 will derive eligibility for free GP services from this new legislation.

But a universal service requires that it is just that – a unitary scheme, available to all children under 6 without distinction. It would be quite wrong – and would run counter to the very objective we are seeking to achieve – if we were to maintain two categories of under 6s and frankly there was never any question of doing so.

For clarity, I should point out that the other medical card entitlements currently enjoyed by children under 6 will not be affected in any way. For example, a child under 6 with a standard medical card will continue to receive their prescription drugs and all other services under the existing GMS scheme.

4. GP Contract

It is clear that the introduction of free GP care for all will require a new contractual framework to be put in place between the HSE and individual general practitioners.

As you know, a draft contract referable to under 6s was issued for public consultation earlier this year. Alongside the draft, we also published a paper setting out the basic principles and components that we see as underpinning any new contract. I think it is important to say that notwithstanding the criticisms that can and have been levelled against it, the draft contract was informed by extensive research and evidence, including the views of expert medical opinion available to the HSE and the Department of Health. In particular, there was reliance on the principles and policies elaborated in Healthy Ireland, in Future Health, and in our eHealth Strategy.

In any event, and as I have repeatedly said, that document was, and remains a draft for consultation. It is formulated for the under 6s, whilst at the same time anticipating the kind of provisions we believe should be contained in a broader contract for the provision of GP services to the whole population. I make no secret of this.

Perhaps because of the lack of communication between us, or a want of trust on all sides, or for whatever reason, the draft has been wrongly characterised as an actual offer to GPs, or as a fait accompli. That was never either our intention or expectation. We have some work to do before we can finalise a contract offering for this new service. So I would characterise it not as a fait accompli but rather as a “work in progress”.

5. Funding of Primary Care

But let me address for a moment the broader context in which GPs find themselves, especially as a result of the economic collapse and the financial crisis that has affected the entire country. There have been significant cuts in health spending, including cuts to professional fees under the FEMPI legislation. I acknowledge that these cuts have had a real impact on doctors’ earnings and on your practices, and many of you have explained this to me as I have met you or visited you in your places of work.

I also acknowledge, and actually agree with your stated position on the need for greater resourcing of primary care – even if I might question some of the figures you have given for the proportion of health spending that goes to this sector.

It is a task for me and for my colleagues in government to fight for more resources for primary care and for general practice. I agree that it is no good talking about the shifting of resources if we do not take steps to achieve it. This is what we must do and what we will do in the coming period, and especially when the new estimates process gets under way later in the year.

Financial certainty, or at least a measure of stability, is essential if GPs are to have confidence in the future, confidence to maintain and build up your practices, and confidence in the case of younger practitioners that they will have a decent livelihood for themselves and their families in their own country. So I say this to you with regard to FEMPI: it is my hope and indeed my genuine expectation that there will be no further need for recourse to the FEMPI legislation, whether in the case of General Practitioners, other health professionals, or public servants. Barring unforeseen events or shocks, the government does not intend to introduce further cuts to public service pay, or cuts to the fees paid to professionals providing services to the State, and I hope that this will give you at least some comfort and reassurance in the period ahead.

6. Where we go from here

Returning to the contract issue and the under 6s legislation, I would like to say a brief word about how matters have been progressing since January. We received over 280 responses during the consultation process on the draft contract, and we have been studying these carefully, including your own submission, which was very helpful. I have also met many individual GPs and listened to their concerns, and all of this has helped me and my officials to reflect on where we are, and indeed to mull over the full range of options and approaches that might be taken. We have been doing this constantly in recent months and will continue to do so.

We have also been doing some background work on a fee structure – comparing the relative merits of capitation, fee per item and performance-based fees – and in this regard we have commissioned independent research from the Economic and Social Research Institute, with whom I along with my officials recently had an extremely helpful session to explore different options.

So there is a great deal of work ongoing.

In order to progress matters to the next stage, we could produce a new draft, taking account as best we can of the various objections and insights that have been communicated to us. But frankly I do not consider that this is the optimal way to proceed at this point.

Meeting and talking to individual GPs is enormously useful and helpful for me, and I will be happy to continue to engage in this way as often as I can. But with respect, what is really needed now is an engagement with the representatives of the IMO to see how best we can proceed through collaboration and agreement.

As you know, I recently wrote offering to meet on a without prejudice basis to explore the potential for engagement, and I am happy that this proposal is being considered. In our correspondence it became clear that you have real difficulties with entering into talks, including concerns regarding the application of competition law to negotiations on a new contract. It is for this reason that I am suggesting a meeting – literally just to talk about how we can engage, and what the agenda for this engagement is to be. We can then each table the items we want to see addressed, whether this is the under 6s contract, the development of the broader contract for the population scheme, the question of resources in general practice, or any other issue of relevance or concern that either side may wish to pursue. I do not set any preconditions for the “agenda-setting” meeting I am proposing but I believe it offers the best hope for us together to chart a way forward.

7. Conclusion

Yes, there are some constraints arising from competition law. I cannot depart from the clear advice I have on this point, but I do say that these restrictions should not be overplayed. There is a huge amount we can achieve – and you can achieve for your members – through engaging in talks now. For my part, I repeat that I stand ready to accommodate you in a real and meaningful process of engagement and negotiation and there is nothing to prevent this happening if there is goodwill on all sides.

I thank you once again for your invitation and courtesy and I look forward to the discussion which will now follow.