asked the Minister for Health if he will make a statement on the result of the recent referendum among doctors regarding his offer of fee per item of service with free choice of doctors under the new Health Act.
Ceisteanna-Questions. Oral Answers. - Free Choice of Doctor Scheme.
12.
I was informed yesterday that the result of the referendum conducted by the Irish Medical Association and the Medical Union on this offer has resulted in a rejection of the terms which I had offered. It is regrettable that this is the outcome.
I should explain to the House that my two predecessors as Minister for Health were involved in talks with the profession on this matter and since I took up office there has been a considerable volume of discussion involving myself, my officials and representatives of the medical bodies. Most of the important points on the form of the scheme and its administration were agreed during these discussions.
In the beginning, the discussions related to a scheme in which payment would be on a basis whereby the doctor would be paid a flat sum per year for each patient, plus an allowance for practice expenses—a capitation system. When, however, the representatives of the profession indicated to my predecessor at a meeting in April, 1969, that they were unwilling to accept the capitation system which had by then been developed, he agreed to establish a study group, representative of the Department and the organisations, to report to him on the manner in which an acceptable fee-for-service method of payment might be adopted.
The recommendations of this group were unanimous. They proposed a simple system of fees for attendances with controls to prevent abuses. I accepted these recommendations and, having studied the existing levels and patterns of remuneration for general practice in this and other countries, I suggested a scale of fees to the organisations last January. This was accepted by them as a basis for discussion and following clarification and consideration of a number of points, I made an improved offer on 28th May last. As it was clear then that the basis for fixing fees could not be finally determined until statistics were available from the actual operation of the scheme, I proposed that an arbitrator should review the scale after one year's operation, with power to make a retrospective adjustment if that should appear then to be justified.
After the medical organisations had considered this second offer, I met them again and as a result made a further substantially improved final offer in July. This offer was notified to the House on 29th July last and is contained in the Official Report, Volume 248, columns 2399 and 2400. The bottom of the range of fees offered is 15s for surgery services in normal working hours —including such calls as for repeat prescriptions. The surgery fees outside these hours are £1 2s 6d up to midnight and £2 5s after midnight. Fees for calls to patients' homes range from £1 2s 6d up to £5 5s. In putting it to the organisations, I pointed out that, in comparing the fees with those in private practice, their members should bear in mind that the fees would be payable for all patient contacts, including such calls as for repeat prescriptions—except for certain attendances solely for social welfare certificates—that fees for public patients would be payable on the basis of a single monthly claim, and that bad debts would not arise. I also reiterated the offer of a subsequent adjustment by arbitration, retrospectively if appropriate.
This is the offer which has been rejected by the members of the organisations. I am satisfied that the terms offered are fair to general practitioners and compare favourably with the remuneration of general practitioners participating elsewhere in the public services. Furthermore in drawing up my proposals I have had regard to the general level of incomes prevailing here and I am satisfied that, in that context, my final offer to the doctors is entirely equitable.
In dealing with this issue, I have always had in the forefront the aim of this House, as expressed in section 58 of the Health Act, 1970, to offer, as far as is practicable, a choice of general practitioner to the lower income group. In all aspects of the proposals, I have been willing to go far to meet the wishes of the profession. It is thus a great disappointment to me that the present situation has arisen but since, as I have said, I regard the offer made as entirely equitable, I cannot make any further offer. Accordingly, I regret to inform the House that 1st April, 1971 will not see the commencement of this highly desirable change in the health services. The existing dispensary system will, of course, continue to operate.
Would the Minister not agree that it is important that the free choice of doctor be implemented as from April? Would it not be a good idea for further meetings to take place as soon as possible and at as frequent intervals as possible to ensure that some form of agreement can be reached so that we can have this free choice of doctor for medical card patients?
Would the Minister not now avail of the situation to embark on a comprehensive survey related to the reorganisation of health services on the basis of insurance, instead of tinkering with the problem? This effort to provide a choice of doctor was an effort merely to bolster up the existing dispensary system. Would the Minister not now consider, if that is not possible, that the entire question of providing a national health service based on insurance should be considered afresh?
I do not propose to complicate the two questions, the choice of doctor service and an examination of the contributory insurance principle. In reply to Deputy Dr. O'Connell, I would naturally take any opportunity of getting in touch with the Irish Medical Association and the Medical Union if I thought it possible that they would accept the offer I have made, which is the final offer. I would remind the Deputy that the proposal to appoint an arbitrator included a proviso that the arbitrator will have before him what we consider to be the average number of services per patient, choosing any one doctor; he will have before him what we consider to be the number of services carried out per day by a doctor engaged in the choice of doctor service as between his private and public patients and also any other matters relevant to the general question of what the fee for service would be. He would also have before him the computerised record of all the fees for services paid to doctors over a period and, based on his judgment and what we consider to be a reasonable income for the doctors concerned, he would be empowered to make proposals to me, the Irish Medical Association and the Medical Union for a revision upwards, if necessary, of the fee for service on a retrospective basis if our assumptions in regard to the number of services per doctor et cetera proved to be an over-estimate. That seems to me to be a very important part of this offer which, if I can recall rightly, is certainly in my experience rather unique in relation to all questions of remuneration—to have an immediate retrospective examination based on certain provisos in respect of incomes. This is quite an unusual way of arranging for a settlement and I think the Irish Medical Association and the Medical Union should have had more regard to this proposal.
Has the Minister any comment to make on a resolution which was passed by the Medical Union that the 15s be accepted as a subvention only of the fee to be charged to patients?
I have no comment to make on that.
Is it not true to say that there are many general practitioners who treat private patients for 15s and, indeed, some for 10s, and am I to assume from the Minister's statement that his offer is fair and just and that he is quite satisfied that it is both fair and just? Why not leave it at that?
Could I ask the Minister how this 15s was arrived at? I think the Minister will admit that you would not get a technician to come and examine the lock on a door for less than 15s. You would not get a technician to come to the house for under 15s.
I hope the Deputy will not start an argument on these lines. Surely we can agree in all parties that there has never been-not that I know of, at any rate-in any European country, a method of job evaluation that would prevent anomalies in payments arising, or prevent the consideration of salaries or wages, or whatever it is, on what might appear to some people to be a fair basis. We have never had job evaluation conducted in such a way that what the Deputy says could be an obviously relevant factor in deciding what a fee for service would be. The Deputy should know that the incomes of professional classes in certain categories may not compare with the salaries of certain types of super-craftsmen. That is a fact of life. I simply could not take it into account in debating such a matter as what the fees for the services of doctors should be or I would get lost in a jungle of comparisons.
The Minister must make up his mind.
Question No. 13.