A proposal for the reform of GP training is outlined by the Competition Authority in its latest report on the profession. Niamh Mullen reports on its findings
The requirement for aspiring GPs to repeat hospital training is costly, inefficient and is limiting the number of new GPs available to treat patients, according to a long-awaited report from the Competition Authority (CA).
The document has proposed a fast-track ‘Phase 2 Orientation Programme’ to allow doctors with relevant hospital-based training to proceed directly to the in-practice phase of GP training and complete the course in two years rather than four.
The Authority was critical of the current GP training model. It said it was out of line with the practice at other surgical or medical training bodies, such as the Royal College of Surgeons in Ireland and the Royal College of Physicians of Ireland.
“Non-recognition of relevant training already completed is inefficient and unjustifiable. It unnecessarily prolongs training for some doctors, with the effect that subsequent registration as a GP is delayed,” it stated.
Currently all programmes require trainees to complete four years of training – two years hospital-based (‘Phase 1’) and two years of GP practice-based training (Phase 2). At present, no recognition is granted to those who have already completed equivalent hospital-based training.
The course proposed by the Authority would be short and intensive, designed to compensate for off-site half-day general practice workshops that form part of ‘Phase 1’, which would have been missed by those who completed other hospital-based training.
The Competition Authority met with the ICGP in 2008 and put forward this proposal. In its Annual Report for last year, the College said it had suggested a proposal to the HSE for the establishment of Phase 2 training. However, it was not approved because it was not ‘budget neutral’.
Director of the CA’s Advocacy Division, Declan Purcell, said the Authority would be reviewing progress of its proposal, but it was now up to the ICGP and HSE to take it further. “If you lined up this orientation programme alongside what it would cost GP trainees to go back to square one, you would find it was less expensive,” he told Irish Medical Times.
The CA report — released before Christmas — argues that the reformed programme would increase the number of GPs qualifying at a greater pace and at a lower cost to the State than by creating more Phase 1 training places.
“The cost of increasing the number of GPs qualifying would be considerably less under this new system. This is because of the savings achieved by eliminating unnecessary duplication of training in Phase 1.”
Ultimately, the Authority said the changes would increase competition between GPs. It added there was general agreement on this issue. However, it acknowledged there were funding implications for the HSE, which were the subject of discussions between the Executive and the ICGP.
Louth GP Dr Ruairi Hanley said it was unfortunate the proposed reforms “come too late for myself and many other doctors who were forced to do the four-year scheme with no recognition of previous experience”.
“Our position has been vindicated. It is just a shame that this situation was allowed to exist for so long,” he told IMT.
GP shortage
The proposal is, of course, prompted in part by the extensively documented shortage of GPs in Ireland. The Authority’s report was the third in 2009 to highlight different aspects of the problem, following similar reports from FÁS and the Economic and Social Research Institute (ESRI). It reiterates that Ireland has only 60 per cent of the number of GPs per thousand population compared to Germany and the US, and only about two-thirds of most European countries.
“There is general agreement that the recognition of prior relevant training would remove a bottleneck in the number of qualified GPs Ireland can produce each year,” it stated.
New advertising guidelines
The CA report also deals with the new advertising guidelines outlined in the recently updated Medical Council Ethical Guide — changes that were lobbied for by the Authority in the form of a detailed submission in 2007. The Authority recommended that restrictions on size, content and placing of signs be removed, as well as the restrictions on distributing price information.
The previous ethical guidelines, for example, stipulated that new practice announcements must be limited to a maximum of 100mm.
In the report, it said a ‘key factor’ preventing the development of competition in the GP profession had been lifted. “It’s now up to GPs, and consumers, to make the new environment work to their mutual benefit.”
As well as benefiting consumers, the proposed changes will also be helpful to establishing GPs who want to advertise their entry into the market. It would encourage GPs to offer ‘new and innovative ways of delivering their service’.
Shopping around
Furthermore, the Authority said it may lead to more competitive pricing because consumers were in a better position to shop around. The report notes the cost of a GP visit has significantly outpaced the rate of inflation in the economy in recent years, with the price between E45 and E60.
“One of the reasons the cost of GP visit has increased more than the cost of living is because it could. There has been no downward pressure. Nobody has been shopping around really. If people are sick, they are sick. They will pay what the market demands,” explained Purcell, who dismissed concerns that practices would rush out to place huge ads in the national media promoting rock bottom prices. “It is not going to be a mad rush to the Blanchardstown Gazette, The Irish Times or TV3.”
The Director of Advocacy said the Authority’s role was to create an environment for competition. “The Competition Authority would not necessarily see anything wrong with doctors advertising prices. That is what everyone else in the economy is doing.”
However, when it came to the issue of quality of services, Purcell said it was something the Authority was wary of.
“We do not want to start dictating what health policy objectives should be,” he stated, adding that it was important there were Medical Council safeguards and standards in place.
College concerns
Chairman of the ICGP Dr Mark Walsh said the College welcomed the support of the Authority for the expansion of GP training, in particular, the proposal for a shortened GP training programme for doctors who attained prior relevant hospital experience. He added that the ICGP was in talks with the HSE and it was hoped training places would be increased from 120 to 160 from July 1, 2010.
On advertising GP services, Dr Walsh said relaxing restrictions would facilitate general practices to provide information to targeted populations and enhance the continuing care relationships between the GPs, patients and the wider community. However, he expressed some reservation about advertising prices.
Question of pricing
“The question of pricing is not a matter for the ICGP, but the manner in which such is promoted or advertised does require detailed consideration and further clarification. The College will be addressing this aspect with the Medical Council and others,” he said in a statement.
The final part of the Competition Authority’s report on the profession, examining the impact of the GMS system, will be published in the first half of next year.
The Authority points out three-in-four GPs have a GMS contract, which provided an average E220,000 in earnings per GP in 2008. “The availability of GMS contracts has a significant influence on the commercial aspects of GP services — such as the location of GP practices throughout the country, and on whether GPs choose to set up in practice on their own or to join an existing practice.”
Among other things, the forthcoming report from the Authority will examine the recommendation of Colm McCarthy’s ‘Special Group on Public Service Numbers and Expenditure Programmes’ — or An Bord Snip Nua — to scrap all GMS contracts and tender for GP services.
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