Land of the free GP

The most striking difference between the health systems on either side of the Border is that patients in the North, regardless of income, are not required to pay for their healthcare. No cash changes hands between doctor and patient for medical treatment. A significant percentage of the population, including children and the elderly, gets prescriptions filled free of charge: others pay a flat fee of £5.80 regardless of the cost of the drug.

But even in this agreeable situation some patients, it appears, are luckier than others. Changes introduced in the early 1990s to health care in the North brought better access to health care for patients of large group practices in the cities, but left patients in rural areas behind.

The proposal to change has been greeted with general relief because even those who have been operating the health services there for the past few years acknowledge it to be complicated and unwieldy.

The main concern now, according to Dr Paula Kilbain, chief executive of the Belfast-based Eastern Health and Social Services Board, is to simplify the system so that people know how it works and how to use it. "Ordinary members of the public must be absolutely bemused at this stage. The hope now is to streamline things and make them simpler," she explains.

Unlike other parts of the UK and the Republic, in the North health and social services are administered together. There are four health and social services boards in Northern Ireland - Northern, Southern, Eastern and Western - covering the population of 1.6 million. They act as agents of the Department of Health and Social Services. Unlike health boards in the Republic, politicians may not, at present, be elected to boards in the North.

Those reforms in the early 1990s, by the Conservative government, led to a separation of purchasing and providing roles - unlike the South. Boards are no longer managerially responsible for delivery of services; this responsibility now lies with trusts.

Instead, as purchasers, boards are required to plan, secure and pay for the services needed to meet the health and social care needs of their population. The trusts, meanwhile, as providers, are responsible for the management of staff and services from hospitals and community services, previously managed by boards. There are 20 trusts in Northern Ireland, each controlling its own budget.

For most people with health problems, their GP is the first port of call. Development of GPs and related services was a key element of the strategy introduced in the early 1990s. In 1993, doctors operating in a large enough practice were given the option of becoming "fund-holders". The number of patients they have, the number they refer to hospital, the costs generated and other related matters determine their budget which is drawn up with the boards.

With their budget, the doctors purchase a range of non-emergency services for their patients including most surgical procedures, outpatient appointments, paramedical services and community nursing services.

Ancilliary services such as physiotherapy, chiropody, counselling, pre-natal classes are also usually available in these larger practices - such GP supports are still unusual in the South. The budget also pays for the drugs prescribed and for practice staff.

Doctors negotiate with hospitals to "buy" procedures. They have the power to bargain and express dissatisfaction about the length of waiting lists for particular procedures or how their patients are treated in hospital. They may opt to send a patient for treatment to England or Scotland if the waiting list in the North for a particular procedure is too long.

If there is money left in the budget at the end of the year, the fund-holders may use it to improve their practice or to provide better services for patients.

Around 100 fund-holding surgeries operate in the North: they cover more than 50 per cent of the population. But change is in the air - scheduled for April 1st, 2000. Much of the change will be aimed at sorting out difficulties caused by fund-holding. Doctors complain that they have less time to spend with patients because they are caught up in negotiating and sorting through paper work. But more seriously, a "two-tier" system has been created. The almost 50 per cent of the population not covered by fund-holding schemes - many in rural areas - are patients of GPs without this "buying power" and clout. The difference between being a patient in a fund-holding practice, or not, is likened to having private health insurance in the South, guaranteeing faster access. There is also a feeling that there is an over-concentration of hospitals and health services in Belfast. People in other areas feel very remote from health services and poorly served by ambulances.

Standards of treatment in hospitals North and South are fairly similar: however, differences do exist. Cancer services in the North have lagged behind but are currently being restructured, while in Belfast's Musgrave Park Hospital, doctors have become leaders in the treatment of trauma, as a result of the Troubles, pushing out the frontiers of rehabilitation medicine.

A further problem with fundholding is that doctors have no budgetary responsibility for emergency admissions. This creates difficulties for boards attempting to budget for treatment for those in non-fundholding practices. They also have responsibility to ensure there are enough resources for emergency admission. A further difficulty was that these doctors who had the power to "buy" operations from a trust hospital could simply decide en bloc to move the following year, because they do not have the same commitments as boards, and risk destabilising the hospital.

The changes to the health system in the early 1990s meant that trust hospitals - as well as GPS - saw a dramatic increase in transaction costs, administration and red tape, since they must deal individually with a large number of fund-holding practices as well as boards.

At the launch of a consultative Green Paper on the future of the health services, "Fit for the Future", the UK's Minister for Health and Social Service, Tony Worthington, said new arrangements for commissioning services will replace GP fundholding. However, he said they planned to "keep the things that work and discard those that don't". At this stage, plans remain vague, and some sources have commented wryly that there is "less to the Green Paper than meets the eye".

One of the changes already evident under the Labour government has been the move to get away from the commercial language used in the existing health system such as "purchasing services" and "buying operations".

Other change is imminent: Worthington has said the new Northern Assembly would give people in the North control over health and social services. If there was consensus, he said, action could be taken quickly. Most importantly, he added, changes in the system in "a Northern Ireland at peace with itself", could be managed by elected local politicians.

More than 5,000 organisations and individuals have been sent copies of "Fit for the Future" as part of the consultation process. In the coming years there will be much change in the health system in the North. The chief executive of the Eastern Board, Dr Paula Kilbain, believes it will mean the service will be "more streamlined and easier understood". Her board has set up a "Citizen's Jury", the first such move of its kind in the North, to find out from people on the ground what sort of changes they feel are needed.

Reflecting on the current system, Dr Kilbain says some aspects are very good. "It was very good to give trusts incentive and responsibility to run their own hospitals as efficiently as they could." However, that system did not encourage them to collaborate - often, indeed, they were pitted against each other commercially in negotiating and attempting to sell medical procedures, which was not in the interest of patients. "If we could get people to collaborate again it would be advantageous and there would be less duplication," Kilbain says.

Fewer trusts, GPs operating in bigger groups and able to spend more time with patients with less "bean counting" would go a long way towards improving the system, she adds.

Tomorrow

Schools apart: Education Correspondent Andy Pollak looks at the radically different approach to schooling North and South