Conor Pope looks at the possible remedies needed to bring transparency and consistency to GP fees
When Mary Harney told the Dáil recently, she was asking Enterprise Minister Micheál Martin whether any of the State's consumer watchdogs could have a role to play regarding charges set by GPs for private patient consultations, she was throwing the cat among the pigeons. Again.
In November 2003 the Director of Consumer Affairs, Carmel Foley, asked Harney, then Minister for Enterprise, for a ministerial order to compel GPs to display a price list in their surgeries. Harney enthusiastically pursued the matter and expressed her confidence that such an order would be in place within weeks.
Even at the time her optimism had an "It'll be over by Christmas" ring to it. The matter wasn't resolved in weeks and more than 12 months passed before Martin, who had taken over at Enterprise, dropped the proposals "for legal and practical reasons".
While Carmel Foley will be the first one to admit that her remit has nothing to do with the prices GPs charge - they can charge whatever they want as long as they tell you about it first - Harney's comments in the Dáil, made in response to a complaint from Pat Rabbitte that GP fees had climbed from an average of €40 to €50, were more pointed.
Whether GP fees are too high is an old argument and one which has passionate advocates on both sides. On the one hand, you have patient lobby groups complaining that spiralling fees have left many sick people avoiding their doctor's surgeries because they simply can't afford the fees.
And on the other hand, doctors' representative groups point out that a GP visit will cost you less than a trip to the hairdressers and significantly less than calling out a plumber and, as such, remains outstandingly good value for money.
Whatever about the relative merits of each position, what is true is that GP fees are rising. A survey published at the beginning of last year indicated that the average cost for a private patient visiting their GP was €36. Now you'll struggle to find a doctor offering consultations for less than €40. The Irish Times contacted more than 12 surgeries across the country last week and €40 was the lowest price quoted while most seemed to charge €45. Some practices in major urban centres charge €60 per visit.
"We are very concerned about the increasing cost of visiting a family doctor," says Stephen McMahon, chairman of the Irish Patients Association (IPA). While he stops short of accusing GPs of price fixing, he says there seems to be a good deal of "commercial telepathy going on" with regard to fees.
He says that prices rose steeply after the introduction of the euro, and climbed again when private insurers introduced schemes to contribute to policyholders' GP bills. "It is becoming important for people to know how much a visit is going to cost," McMahon says. "These costs should be flagged."
The Irish Medical Organisation (IMO) was involved in discussions with the Department of Enterprise about the implementation of the ministerial order last year. Although it has no role in the setting of private GP fees, it was asked to advise the department on the range of services GPs provided. While the IMO co-operated fully, it supported the Minister's decision not to proceed with implementation because it felt it was "impractical and unenforceable".
Although some GPS display the cost of a consulation in their surgeries, there is no legal obligation on them to do so.
Dr Martin Daly, chairman of the IMO's general practitioners committee, says if a simple price list were used, as outlined in the order, there was a risk patients would think all procedures were covered by it. One way around this, the IMO suggested, was for surgeries to carry a list of prices for up to 85 different services. However, this individual pricing of all procedures may have resulted in higher charges for patients overall.
The fear was that GPs could suddenly start charging not just for the consultation, as is the case now, but for the individual items on the price lists they were forced to display.
Patients would then end up paying one amount for having their blood pressure taken and an extra charge for having their reflexes checked, even though the two procedures formed part of the same consultation.
"We had a view that if GPs were forced to define the value of each additional service and display it in their surgeries, it would have had the effect of pushing fees up rather than keeping them stable," Daly says.
He accuses the Minister for Health of unfairly targeting GPs: "Mary Harney is a politician who is coming into a general election cycle. It is the populist stance to take to denigrate and demonise GPs as a grouping and question the value of their service."
He says repeated surveys both by the Department of Health and outside consultants have shown general practices in the Republic to be "exceptionally good value for money. We are an easy target for politicians."
The IPA's Steve McMahon says that the higher prices GPs are charging could leave them exposed to outside competition in the future. "We do live in one of the most open economies in the world," he says.
Providing certain healthcare services is attractive, he says. "Because the margins are so big, health professionals from abroad have approached us seeking information about the provision of services."
It is uncertain if these include GP services, which in some cases are not as financially lucrative as many suppose. Daly points to the case of a colleague who was charged €60,000 rent for a surgery in Swords.
The gross fees from his 600 medical card patients amounted to €135,000. When nursing, secretarial and pension contributions were deducted but before he had paid other overheads, including the €60,000 rent, he was left with around €90,000. "That reflects a serious disincentive for GPs to set up," he says, leading to "difficulty in recruiting and retaining GPs in north Dublin but also in many parts of the country".
"It is worth noting that the day is long gone when the GP sets up in their own home or in the garage attached to their house - planning laws preclude this from happening any more," he says.
Carmel Foley remains convinced the ministerial order is important, not to keep prices in check, but to ensure fairness and full transparency. "Why should professionals consider themselves immune from displaying prices," she says. "It is good practice."
She has expressed her hope that with the new impetus from the Department of Health, progress can finally be made on the issue. She says that on the last occasion an attempt was made to compel GPs to carry prices in their surgeries, the stumbling block appears to have been that existing legislation on pricing was too narrow.
"If it is not possible to implement the order with the narrowly drawn legislation," she says "then let's amend that legislation so that doctors could display indicative or common prices. I would hate to see the letter of the law being used to avoid transparency.
"If the IMO thinks there would be confusion then it itself could provide guidelines to its members as to how to best inform their patients of prices," Foley says. She has also called on GPs to voluntarily tell people about the costs and have some sort of indicative list of prices.
"I applaud those who do provide lists. The day when professionals were immune from questioning and immune from discussion about value for money are gone."