Dáil Éireann díospóireacht -
Wednesday, 6 Jun 1990

Vol. 399 No. 7

Ceisteanna—Questions. Oral Answers. - Payment System for Doctors.

Joe Sherlock

Ceist:

13 Mr. Sherlock asked the Minister for Health if any assessment has been carried out of the cost effectiveness of the change over from the fee per item to the capitation system of payment of doctors under the general medical service and the quality of medical cover; if any such survey is planned; if he will give the highest figures for payments to doctors for the last year under the old system and the number of patients receiving cover; if he will give the relevant figures for the new system since it came into operation; and if he will make a statement on the matter.

Dr. O'Hanlon

The capitation-based payments system now in operation for the vast majority of doctors participating in the GMS provides for a review of the scheme after the first 12 months and at three-yearly intervals thereafter. The first such review — including an independent expert examination of the financial consequences of the new arrangements — is currently in train. The review will inter alia investigate the extent to which the objectives of the new scheme have been met.

I have been informed by the General Medical Services — Payments — Board that they have replied to the Deputy with regard to the data sought in the latter part of the question.

Mr. Sherlock

I am disappointed at the Minister's reply because I had received that information from the GMS. Would the Minister say: what is the difference in cost between the present capitation system of payment to doctors operating within the GMS scheme and the fee per item system; also whether the quality of the service being provided is satisfactory? Has there been a survey carried out to ascertain whether the quality of the cover being provided is up to standard; whether the numbers of people fully eligible under the provisions of the scheme — which seemingly is costing more — has been examined by the Minister? What I am asking about is the quality of the cover being provided and its cost; whether it is costing more under the GMS scheme to treat fewer people, because I understand the percentage of people who are fully eligible has dropped from approximately 39 per cent to 32 per cent?

Dr. O'Hanlon

As I said in my reply, the GMS Payments Board did reply directly to the Deputy. My understanding is that their annual report has not yet been completed and will not be available until the month of August; that it will take account of two months during which the old scheme was in operation and ten months during which the new scheme has been in operation.

Mr. Howlin

In relation to the review that is in train, would the Minister say whether the views of medical card holders in relation to the medical service consequences of the change over will be surveyed and their views taken into account in relation to any changes that may be implemented?

Dr. O'Hanlon

Yes, certainly we would be interested in the views of medical card holders in the scheme change.

Mr. Howlin

A specific survey?

Dr. O'Hanlon

I could not guarantee a specific survey; that is not included in the question. However, I will take the matter up with my Department and examine what can be done to ascertain their views.

Mr. Yates

Arising out of the change in the GMS from the fee per item to the capitation system of payment of doctors, is the Minister aware of the increase in the number of admissions to accident and emergency departments of hospitals because of the allegation that general practitioners, particularly at night — since they are no longer being paid for visits at night — are advising people to go to hospital instead, and that this involves the health services in a spiral of extra cost in respect of people who do not necessarily need to go into hospital? As part of the review in train would he have this matter thoroughly investigated, or does he have any information on it to date?

Dr. O'Hanlon

I am not so aware. In Dublin where very detailed surveys have been undertaken my information is that the number of people who turn up at accident and emergency departments without a note from their general practitioner is 60 per cent, and that that has not changed in hospitals where a survey was conducted before the changes took place. My information is that that pattern did not change from what had been the case heretofore. There is a particular problem prevailing in Dublin — to which I have referred on many occasions in this House — in that, in some areas, there is not continuity of general practitioner service. Throughout Dublin generally I understand there is a tendency on the part of patients to by-pass their general practitioner and go straight to an accident or emergency department. But there is no evidence to suggest there has been any increased use of the accident and emergency services since the change over.

Mr. Finucane

I am sure the Minister is well aware of the extreme concern among the medical profession at the operation of this new capitation system of payment of doctors. Looking realistically at its economics — in regard to overhead costs, retention and so on — would the Minister agree that the amount of money that eventually finds its way to doctors is so little that, in order to provide a continuous service throughout the year, there is a tendency for them to refer patients to casualty departments? For example I am aware that in the mid-west alone, at the Limerick Regional Hospital, the number of casualties have risen recently from approximately 1,100 a week, that is up 40 per cent on the previous year. Would the Minister agree that there is a tendency in that direction?

Dr. O'Hanlon

I do not accept the point the Deputy made. In fact there was quite a substantial increase in the amount of money made available to doctors, both directly and by way of a number of support mechanisms, such as the provision of support towards practice premises and in the provision of secretarial and nursing help. Indeed the doctors themselves voted substantially to accept the new arrangement.

Mrs. Owen

In view of the fact that the Minister does not have any real, hard information for the House today, would he include in the survey an opinion as to whether there has been an increase in the use of medical bureaus, when general practitioners resort to a telephone answering service and people are referred elsewhere? Such detail might give an indication of whether the system is operating satisfactorily.

With regard to acceptance of this capitation system of payment by doctors, has the Minister fulfilled all the commitments he agreed with the Medical Union on its introduction, such as pension rights and so on, agreed with the medical profession?

Dr. O'Hanlon

I do not have access to the information the Deputy seeks in regard to medical bureaus because that is a private arrangement between them and general practitioners.

With regard to the agreement, I should say I do not have details of every aspect of it that was implemented. In regard to pensions I should say the State honours its commitment and provides 10 per cent towards doctors pensions, the doctors themselves providing 5 per cent, which money has been lodged. I would not know whether doctors have arranged a pension scheme at this stage. That is a matter for the doctors themselves.