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'We are not the HSE's dumping ground' - after 48 years, is the State finally set to update its contract with GPs?

The current General Medical Services agreement between the government and GPs dates from 1970.

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RECENTLY, A NUMBER of stories have emerged regarding claims that the HSE has refused to reimburse some medical card patients for blood tests taken by general practitioners (GPs).

Many GPs across the country charge for what they perceive as non-urgent blood tests, for the management of chronic diseases like heart disease or hypothyroidism.

Charges for such tests range in cost from anything between €10 and €35.

The issue has led to a dispute between GPs and the HSE/Department of Health, over what the contract between the two actually covers and what it doesn’t.

That agreement dates from 1970. It’s one that isn’t fit for purpose, and hasn’t been for a long time, according to one GP, based in the midlands, who spoke to TheJournal.ie, after being penalised by the HSE when a patient complained to their local primary care centre that they were being charged for such routine tests.

“The dispute over blood tests isn’t about money,” he says. “Most of us would have performed them for years for free anyway, so the HSE wants it to be covered by the contract. That’s the problem, it isn’t.”


He explains that many GPs first began charging for the tests at the time the first FEMPI (Financial Emergency Measures in the Public Interest) measures were introduced 10 years ago, with many GPs suffering consequent funding cuts of up to 40% as a result.

“Few will have sympathy for a GP, there aren’t many of us who will be badly off, but that doesn’t make the contract right,” the GP says.

The 1970 GMS (General Medical Services) contract covers acute medical care (a chest infection, or a bladder infection say), not chronic disease management – that is, the management of long-term illnesses via (mostly) non-specialised care.

“That’s because chronic disease management basically didn’t exist in 1970. Medical care has changed. The contract hasn’t,” the GP says.

7/3/2018 Eighth Amendment Supreme Court Judgements Minister for Health Simon Harris Source: Leah Farrell/Rollingnews.ie

So you’ll have people getting five blood tests a year, plus a full check-up which they don’t need. That’s not what the contract was put in place for. And you can’t blame them. People will always get what they can for free. If they had to pay for it they wouldn’t do it. But it shouldn’t be us who foots the bill. We are not the HSE’s dumping ground.
That will make general practice unviable, as it already is as a profession for many graduates, who are choosing to leave the country.

Part of the problem is a feeling on behalf of GPs that, when they signed up to free care for those under-six (and for those aged over-70), the carrot offered by the Department of Health was an imminent renegotiation of the State contract. That was in June 2015 (ironically, State-sponsored care for registered diabetics was introduced at this time, suggesting that particular disease wasn’t in fact covered by the older contract). It still hasn’t happened.

“GPs have to work harder since the provision of that kind of care. Because we’re busier, because hospitals need more care to be provided efficiently in the community to help them function,” our source says. “At the same time, the State is obliged to provide phlebotomy (blood test) services for free at hospitals for all patients, not just those with medical cards. But they don’t tell people that, they don’t advertise it. There’s no reason to attend your GP. But that’s what happens.”

It isn’t about money, it’s about principles. We are not the soft touch the HSE seems to believe we are, or at least we can’t behave like we are.

That stance regarding blood tests, and the need to update the GMS contract, is endorsed by both the National Association of General Practitioners (NAGP) and the Irish Medical Organisation (IMO).

“The contract is supposed to have been ‘negotiated imminently’ for the past few years, they say it and they keep saying it,” says Andy Jordan, chairman of the NAGP. “It’s painful watching it. The next date we’ve heard is next month for discussions to begin, as in April. And all we’ve had up to now is discussions, not real negotiations. I believe the IMO’s position is the same. Also, it’s hard to imagine how a contract can be put in place when FEMPI is still in situ.”

This contract is 40 years old, it’s a sickness contract, it’s not for disease management. And something has to be done. Even at the moment the general practice system is under terrible pressure, especially in rural areas, remote or deprived areas where most patients have medical cards.

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TheJournal.ie queried the Department of Health regarding the 48-year-old GMS contract. A spokesperson replied that “contract consultations are a priority for 2018″.

“It is generally accepted that there is a need to modernise the current GMS contract and ensure that general practice benefits patients, and is a viable and rewarding career for current GPs as well as future medical graduates. The overall aim is to develop a contractual framework that has a population health focus, providing in particular for health promotion, disease prevention and the structured care of chronic conditions,” they said.

Engagement with GP representatives is due to commence in the coming weeks.

They added that it’s not currently possible to indicate “a definitive timeline” regarding those discussions.

“It is hoped that agreement can be reached with GP representatives on a package of measures and reforms which, if agreed, will result in an expansion in the scope of the service provided by GPs to holders of medical and GP visit cards.”

How that final statement will be received by GPs themselves remains to be seen.

“There are other issues at play here,” says our source. “Right now it’s close to impossible to get locum (agency) cover for a practice, because the work isn’t that attractive. It all feeds from the same thing – there are nicer ways of making your money.”

These things do play into that – that’s part and parcel of feeling like you’re a valued member of a health service, rather than the HSE feeling like ‘why wouldn’t they do all this, what else are they going to be doing’.

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