Paying for General Practice:
the Past and the Future
Dr. Martin White
General Practitioner
Nobber
Co. Meath
1
Clinical Background
• UCD Graduate, 1976
• Vocationally Trained GP (Canada)
• Member of Colleges of General Practice of
Canada, UK and Ireland
• 30 Years a Principal in a Rural Practice
• 3 Partners, Post Graduate Training and
Research Practice, Computerised for 15
years
2
Non Clinical Background
• Involved in a range of National and Local
Negotiations on behalf of General Practice:
1988-2008 including GMS Contract
• Trustee of GMS Pension Fund (since 1979)
• Founding member of North East Doctor On Call
(The first large Out of Hours Co-Op in Ireland)
• IT Tutor (Regional)
• HeartWatch Tutor (Regional)
3
Paying for General Practice
Services
GP’ are:
• Self Employed
• Independent Contractors
Canada: Universal Coverage
•
•
•
•
Practice Registration – No
Payment: Fee per Item of Service
Out of Hours Service: Hourly Rate
In Evolution
4
Paying for General Practice
Services (cont.)
Ireland:
•
•
Mixed: Private : Public approx 65 : 35 %
Practice Registration – Partial
Private : Fee per Item of Service
Public :
•
•
•
Pre 1989 GMS Contract: Fee per item of service
1989 GMS Contract: predominantly Capitation based system
Universal Coverage: Fee per item of Service
Maternity& InfantCare
Childhood Vaccinations
Cervical Screening
Some Chronic Illness ( HeartWatch, DiabetesWatch)
•
Out of Hours Service: Fee per item of Service
5
Paying for General Practice
Services (cont.)
Holland
• Pre 2005 Mixed: Private/Public
•
•
•
•
•
Now: Universal Coverage Social Insurance
Practice Registration - Yes
Payment: Mainly Fee per item of Service
Partly Capitation
Out of Hours Service: Hourly Rate
The future for General Practice in Ireland
•
•
•
•
No Change
Extend GMS to all
NHS Model (NI and UK)
Universal Social Insurance
6
Would GP's Support Dutch Model of
Universal Health Insurance?
Pro’s
• Nature of General Practice: Equality
• If similar UHI for Hospital System & Consultant
Contracts
• Value Added : Universal Registration / Information
Technology
• Gatekeeper Role
• Payment for Work done
• Out of Hours Structure & Payment
• GP's are by Nature Innovative/Adaptive/Pragmatic…pro
change
7
Would GP's Support Dutch Model of
Universal Health Insurance? (cont.)
Cons:




Funding / Payment including Staff Grants Pension and Locum Payments
Deficient Hospital and 2o. Care Systems
Deficient Primary Care Supports
Workload: Short Consultations

The Model:
a) Simplistic & Single Fit:: Service Driven High Patient / Dr. Ratio
b) Poor Fit for New Challenges: Chronic Illness Care, Mental Health
etc.
c) Demographic / Geographic Issues
•
•
? Lower Patient Satisfaction Rates
Increased Bureaucracy
8
Barriers to Change
1. Rebuilding Trust: De-Politicisation
Replace Adhoc Policy and Crisis Negotiations
(i.e.) Over 70's Medical Cards:
Deregulation of GMS Contracts:
Primary Care Teams
with Vision and Planning, and Shared Memory
a) Consensus:
DOH IMO/ICGP
b) Engagement: Negotiating Rights
9
Barriers to Change (cont.)
2. Understanding GP's Role and
Measurable Health Gains
 Personal / Family Care Needs
 Community Needs
 Wider Goals:
a.) Health Delivery Models and Integration
b.) Relevant Quality and Health Gain Measurements
c.) Targeting Resources Appropriately
d.) Ownership / Co-Operation / Transparency
e.) Independent Review Process and Remodelling
10
Will It Happen ?
Not in Isolation
Consensus
Leadership
Bottom Up
Time Scale
Don’t Tear the Whole House Down
Yes !!
12
13
Any Questions?
Thank you!
14