How are GPs coping with free care for under-6s?
Out-of-hours GP services are bearing the brunt of increased attendances since the introduction of the free GP visit card for children aged under six
GP visits: People with medical cards attend GPs, on average, six times a year, compared with a private patient average of twice a year. Now that GP visits are free for children under six, they are likely to come more often. Photograph: Thinkstock
Out-of-hours GP services are bearing the brunt of increased attendances since the introduction last July of the free GP visit card for children aged under six.
That is hardly surprising when you consider that 40 per cent of the population were already entitled to free GP visits through having a medical card. So those now eligible among the other 60 per cent are more likely to be families where both parents are working and it may be only the evening or weekend when they have the chance to do something about concerns for the health of a child.
In Limerick, for instance, there has been a 42 per cent increase in out-of-hour attendances by under-sixes, according to local GP Dr Emmet Kerin, who is president of the National Association of General Practitioners (NAGP).
“The knock-on effect of that is it is displacing people who need to be seen on an urgent basis,” he says, pointing out that the out-of-hour system is not designed for routine appointments.
There is speculation that this extra pressure on out-of-hours doctors results in more referrals to hospital emergency departments, although Kerin doesn’t attribute the 18-20 per cent increase in attendances at Limerick hospital’s emergency department as solely due to the new scheme.
“It could be the type of winter we’ve had,” says the Ennis Road GP, who chose to stay out of the under-sixes scheme.
According to the latest figures from the HSE (see panel), 2,274 GPs have signed under-six contracts – that is 93 per cent of the 2,452 with GMS contracts.
Effect on GPs The effect on GPs depends on the areas in which they operate, says Dr Mark Murphy, chairman of communications for the Irish College of General Practitioners (ICGP).
There has been no change at all in some practices in the more disadvantaged areas of Dublin because their under-sixes were already on medical cards, he says, but those in more prosperous areas have certainly seen a bump in attendances.
Kerin says he lost some private patients initially because he didn’t register for the scheme “and some came back”. He also has some new patients with under-sixes “because they can’t get to see their own GP and they are willing to pay for the service – we charge a reduced fee for kids”.
He is all for universal access and free GP care but says that requires a functioning, resourced general practice. “What is happening now is it is overwhelmed and degrading the level of service.”
It is too early, Murphy says, to see all the effects, both positive and negative, that the under-sixes policy will have.
While the ICGP supports the free care and sees it as beneficial for patients, “it does have a major influence on capacity”, he says. For some practices, it is a major cause of them being “really stretched”.
Number of visits People with medical cards attend GPs, on average, six times a year, compared with a private patient average of twice a year. Now that GP visits are free for children under six, they are likely to come more often, he agrees, but that doesn’t mean they are unnecessary visits.
It could be “appropriate” attendance, whereas before they were “inappropriately” staying away because of financial issues, says Murphy, who is a GP in south Dublin.
However, a huge amount of the GP workload is under-six illnesses and the vast majority of those are viral illnesses where there are no complications and very low referral rates to hospital, he says.
To help parents, and others,to read and manage the symptoms of these minor illnesses, the ICGP has collaborated with the HSE and the Irish Pharmacy Union to set up the website, undertheweather.ie.
“It gives them accredited, consistent accurate advice about what they should do about these mild symptoms and when they should go to the GP.”
It remains to be seen whether there will be a drop in prescribing of antibiotics to children now there is less pressure on doctors to give parents something tangible to make them feel the visit was worthwhile.
“I do think we have to be honest,” says Murphy. “When there is a market in healthcare and there is a fee at the point of contact, that does change the doctor- patient relationship and it can have consequences and incentives.
“Removing the financial barrier in the transaction, I would say, makes it easier for the physician and GPs to negotiate a management plan which often excludes the use of antibiotics.” Anecdotally, he adds, GPs are saying consultations involving the under-sixes are quicker and easier now but more frequent.
Niamh Cassidy, who has two sons, aged 2½ and two months, believes the free GP visit card “hasn’t made us more likely to attend but has taken away any financial stress around it”.
She and her partner, who live in Dublin 13, applied for a card for the older boy shortly after the scheme came in and they were glad their GP had signed up for it.
“I would have reluctantly changed doctors had she not,” says Cassidy, who reckons they have used the card two or three times – and twice it was out of hours.
Waiting times She hasn’t noticed any increase in waiting times at her GP’s practice because “it’s always difficult to get an appointment, unfortunately. It has been harder to get a D Doc [out-of-hours] appointment though.”
She says the scheme gives them peace of mind that finances are no longer a consideration when deciding whether or not to bring a child to the GP. “Sometimes you might have an instinctual concern but not want to waste money; having free care takes away that concern,” she adds. “Also, if there’s a time at the end of the month when finances are tight, it stops you adding more debt to your credit card.”