We may be paying more and more for our GP visits, but just how much of our money makes its way into our doctors' pockets? David Labanyi writes.
How much do you think your local GP earns? Too much or not enough? Perhaps you've no idea.
Well, the average GP earns "somewhere in the region of €80,000 to €100,000" per annum, although some earn considerably more, others considerably less, says Dr James Reilly, the recently appointed chairman of the Irish Medical Organisation (IMO).
The perception that general practice is well rewarded stems from the fees paid by private patients and data from the General Medical Services (GMS) Payments Board.
In its 2002 annual report, the GMS said 200 GPs earned over €240,000 each with a further 353 GPs earning over €180,000 a year for treating medical card patients.
The average fee paid to family doctors for treating medical card patients rose by €50 to €221, due in part to the higher rate paid for new over-70 patients. As a result, the cost of the scheme rose €70 million to €271 million while the number of people entitled to a medical card dropped by 30,000.
Dr Reilly says GMS data ignore the costs of providing primary care. While many practices turn over up to €400,000 per annum, "when they've paid their costs, yes, some are on €100,000 a year but many are back on between €50,000 to 60,000."
Estimating revenue from private patients is difficult, according to Dr Reilly.
When asked to explain the divergence in GP fees, varying between €20 and over €50, Dr Reilly says: "There is an issue around why there is such a variation in GP costs, why different GPs charge different quantums of money for their consultation."
The Tánaiste, Ms Harney, said in January that she was planning to investigate the fees charged by GPs following complaints from consumer groups.
Dr Reilly suggests in some cases that higher fees reflect that a GP has a specialisation in a particular area. "The other influencing factor would be overheads," with two key costs identified - finding a premises and the cost of time off.
"The provision of premises is just killing it [general practice]. It is killing it for anyone trying to come in," says Dr Reilly. Family doctors can no longer "practice from your converted sitting room, or converted garage, you must practice on a commercially zoned area. GPs are facing ground rents of €60,000 or €70,000."
He suggests the impact of costs on GP consultation fees can be seen in Ballymun where a primary care facility was built by the local health board. Free of infrastructure costs, its GPs charge an "uneconomic fee" of €30 per consultation, one of the lowest in Dublin.
For rural GPs the opposite is the case. Premises are plentiful but time off is the problem.
Some rural GPs "are turning over serious money, but it is being consumed by trying to get time off", says Dr Reilly.
A rural doctor seeking a weekend off, a holiday or maternity leave has two options: hire a relief GP, or locum, at his or her own expense, or join a GP co-op in their area.
Dr Sean McGuire, chairman of the Irish Association of GP Co-ops, says about half of the 2,500 GPs in the State are co-op members, and many more wish to join.
Co-ops are private enterprises which provide out-of-hours cover for GPs within an adjoining area.
Under the GMS contract, GPs are required to provide an out-of-hours service.
Participating GPs pay about €7,000 per annum. This contributes towards capital costs, providing a nurse to answer calls 24 hours a day and equipping a vehicle with the necessary medical equipment for the use of the on-call doctor.
Although the Department of Health has contributed over €46 million to support the establishment of co-ops, Dr McGuire says a lack of additional Department funding this year means the roll-out of new co-ops is stalled.
GPs outside co-ops have to pay for a relief doctor. These are provided by Locomotion, an agency which has about 50 qualified family doctors, and charges 1,650 per week, €900 for weekends and €210 for weekdays.
With these difficulties and costs, does general practice remain attractive?
The answer is yes, according to Dr Richard Brennan, chairman of the Irish College of General Practitioners (ICGP), which trains family doctors. Last September there were twice as many applications as the 84 general practice training places could accommodate.
Dr Brennan highlights the "confusion in the public mind between what GPs earn and what is turnover". Using the example of medical card income, Dr Brennan says: "A third of that money never comes into the practice because it is taken in retention tax. Then you are looking at costs in the order of 40 per cent.
"If you employ staff, secretaries or nurses or if you computerise your practice, and \ medical defence insurance, rent, rates etc, the actual income you derive from your medical card fees is only a very small proportion of what is paid."
People reading about differences in GP charges may wonder if these reflect different standards of care.
Stephen McMahon of the Patients' Focus group, says it is "impossible to quantify whether GPs charging more are providing a better service or just responding to economic pressures or the resources of their catchment area. We would think that in the area of medical cards, that there shouldn't be a difference in the level of service."
And Dr Brennan says "in terms of care, the answer is no, the quality of care is consistently quite high, but it is restricted by the environment that they work in."
Some larger primary care centres have an additional range of facilities and expertise which is not available in a "single-handed rural practice".
What is causing concern for the IMO, the ICGP and patients' groups is that the working environment is increasingly determining where GPs choose to practice.
The IMO and ICGP both see GPs eschewing deprived areas in favour of private patients or over-70s medical card patients.
New GPs are able to choose because of the manpower crisis in general practice. Because the number of graduates is only half the number of family doctors who retire each year, this shortage is worsening.
According to the ICGP, Ireland has one family doctor for every 1,772 people. In the UK, this ratio is 1 to 1,467, and it, too, claims a GP shortage.
" are going into private partnerships with no GMS commitment. They don't see the GMS contract as being attractive. It is a 24-hour-a-day, seven-days-a-week contract - with no incentives, to work in a deprived area and no tax incentives to allow you to develop the practice," says Dr Brennan.
In certain areas the shortages are more pronounced. North Dublin has a ratio of one family doctor for every 2,500 patients. Practices in counties Kerry, Sligo, and Kilkenny have also had problems with recruitment, says Dr Brennan.
An example of the difficulties was highlighted when the Northern Area Health Board recently advertised for a GP to take a list of medical card patients, and it received no applications and the position had to be readvertised.
Dr Brennan says the move away from poorer areas reflects the frustrations of GPs. "They have terrible difficulties accessing hospital services. \ just don't want to work in these areas."
He admits there is concern in the ICGP at the number of GPs avoiding practices in deprived areas. He says this trend is one of the reasons the college is seeking a manpower group to examine GP staffing.