Ensuring a balanced approach to reforms

You wait for years for any significant reports to come along about how to bring about reform of the health service, and then two come along together, says Dara Gantly

We have all found ourselves in the situation where we’re heading off on our two-week holidays and wish to clear our desk of any outstanding business, answer those neglected emails and letters, and make sure colleagues are prepared for any events during our absence.
It’s usually a hectic time, but it can also be a satisfying one. Of course, when one’s holidays are 12 weeks long, expect the clear out to be on an altogether different scale.
So after all the recent Oireachtas talk of bitches and stags, Dáil deputies have shut up shop until September 29 next. But not until the guillotine was employed on several important bills before the summer recess, and numerous weighty reports were published by the various Government departments.
And they don’t come much heavier than the Report of the Expert Group on Resource Allocation and Financing in the Health Sector (850g), and its two accompanying tomes explaining the evidence for the expert group — volume I weighed in at 1.13kg on the office scale, while volume II was off the scale, literally.
But there is substance there, too. The group gathered evidence on best practice from around the world, analysed stated health policy in Ireland, compared current arrangements with guiding principles, and recommended actions based on these principles.
The group agreed, where possible, that we should avoid major reform and its inevitable costs. The current shift to local delivery of services within national policy was, it felt, in the right direction – its only concerns are about detail and scale.
According to TCD’s Prof Charles Normand, a member of the Expert Group who spoke at its launch last week, the aim was to change how things work, not what shape they are.
So what changes have been suggested? The group does not recommend a change from the present mainly tax-based financing of healthcare to universal/social health insurance. It believes ‘prospective’-based funding as a method of reimbursing healthcare providers should be introduced, beginning in the acute hospital sector. As this is rolled out, the National Treatment Purchase Fund’s functions should be ‘mainstreamed’ within the HSE.
Perhaps the most radical element of the report is the suggested new graduated form of eligibility, which is aimed at better addressing the burden of chronic-disease management.
Four types of primary-care cards would replace existing schemes, so as to incentivise the shift from acute hospital to more appropriate primary-care settings and the end of the “overreliance on hospitals as a source of services” for patients.
The Expert Group report also said a review of the GP contract was overdue, a sentiment echoed by perhaps a more far-reaching report published on the same day by the Competition Authority (CA).
The final part of a three-part investigation on competition among GPs, the long–awaited report has recommended that access to GMS contracts should be opened up to all qualified GPs, and that those in possession of a contract should be free to set up in, or move to, the location of their choice.
The CA also believes that decisions to award a GMS list in a particular area should not have to take account of the viability of GPs already practising in the area, and that the interview system for awarding contracts should no longer favour GPs who already have a GMS contract over those who don’t.
For establishing GPs, the implementation of the report in full would resolve all the issues facing those struggling to get on the first rung of the primary-care ladder. Up to now, the majority of newly-qualified GPs have either had to work in existing practices, as an assistant (26 per cent), on a sessional basis (22 per cent) or as a locum (12 per cent). Only 10 per cent of newly-qualified GPs work as GP principals, either on their own or in partnership with others.
However, what it doesn’t fully address is the real possibility of rural or deprived urban areas suffering by finding it difficult to recruit doctors in this new open and competitive market. We all recall Roundstone, Co Galway.
While the Authority welcomed the recent relaxation of the rules on entry to the GMS as a “step in the right direction”, it believed the agreement did not address the underlying constraints on competition. Indeed, it said the ‘concession’ awarded to GPs applying under the 2009 provisions was in reality “very modest”.
“In any market, reducing the number of eligible suppliers will tend to put upward pressure on costs. This is all the more likely where there is an overall shortage of suppliers (GPs) in the first place.”
However, the Authority pulled back from the nuclear option of recommending competitive tendering for GMS lists. It said the case for moving to such a system was “not clear” and “at a very early stage of development”.
“We favour instead changing the existing system of GMS contracts to allow competition to operate more efficiently within it,” the CA report added.
More worrying for the IMO is the recommendation that payments to GPs under the GMS should not be decided on the basis of agreement with the union, but should be decided by the Minister for Health, following consultation with GPs, and the IMO, “if desired”.
“It may ultimately prove easier and more effective to terminate the existing contract and start afresh with a clean slate rather than seek to amend the existing contract,” the Competition Authority added. It is clear the IMO will have to fight its corner hard in this regard.
So of the two reports, the latter from the Competition Authority is perhaps the most far reaching for the profession. It holds promise to some areas, but dangers in others. And as with all scales, getting the balance right will be essential.