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Why Free GP care risks making the health system worse

The ESRI produced for the Government, yesterday, a study of dubious utility. The cost of providing free GP care to the whole population, they bravely predicted, would be somewhere between €381m per year, and €881m per year. Just the odd half billion, then, in the range. It could cost one amount, or it could cost more than twice that amount. With expert predictions so precise, who’d be a Minister, in charge of budgeting for these things?

In truth, the cost of providing free GP care is probably what should worry us the least. Even if the ESRI’s worst case scenario for the cost of doing this is off by a factor of 50%, and the cost were €1.75billion per year, that would still be a relatively small addition to the 23billion annual health budget, if we think that free GP care would make the health system better.

The bigger issue is this: There is no reason to believe it would make the health service better, and many to believe it would make the health service worse. Stick with me, here.

Let’s start with the most basic argument for free GP care: That argument would be that the cost of a GP visit for those who do not already get it free is a reason why those people do not go to their GP when they are sick. They cannot afford the €50 or €60 that it costs. The basic laws of supply and demand dictate that when the price of something falls, demand for it rises. Therefore, we should all agree, when the cost of GP care falls to zero, demand will rise substantially.

This would not be a problem if supply also increased. But in fact, one of the big issues in Irish healthcare is that the supply and demand relationship for GPs has been broken for a long, long time: In layman’s terms, there are not enough GPs as it is.

Here is the Irish Examiner, from June of last year:

Our population is at its highest in 200 years and that growth has  increased the difficulty in accessing a GP.

It is a challenge not just for people who move to a new area, but even patients who have a doctor are finding it harder to get an appointment, and they include medical-card patients…..

….Most practices are no longer taking on new patients, the chair of the Southdoc out-of-hours service for Co Cork and Co Kerry said this week.

Dr Joanne Montgomery said patients are coming at night, because they do not have regular GP access.

Dr Montgomery said there are a number of reasons behind the delays for patients.

“Most GPs would retire at 70, but now people in their 50s are looking for exit strategies. Now it’s younger people looking at that,” she said.

There is a big crisis looming. I think all medical people are very tired after the last couple of years. There is a bit of battle-fatigue and people who wouldn’t have thought about retiring are, now.”

That “big crisis” was looming, you’ll note, before the present proposal to dramatically increase demand for GPs.

Now normally, in economics, when demand increases, supply should naturally increase to match it. In theory, if there is more demand for GPs, then that should make being a GP more attractive than it presently is, and draw more doctors into general practice. But there are many, many reasons to doubt that this is true, and several more reasons to wonder whether, even if it was true, it is a good idea.

In the first instance, there is already excess demand for GPs, but no evidence that supply is growing. In fact, increased demand seems to be having a negative effect on GPs: Because a GP’s surgery is over-subscribed, money is not an issue. Doctors can see all the patients they have time to see, and make a good living. No, the trouble appears to be quality of life. Many doctors, anecdotally, are working 12 or 13 hour days, with few breaks. When they are not seeing patients, the various HSE schemes, from medical cards to free covid consultations, and so on, demand hours of paperwork and form filling and reclaiming of expenses.

Free GP care for everyone, of course, will add to all that form-filling and paperwork and claiming of costs back from the HSE.

And so, the Examiner reports, “people in their 50s are looking for exit strategies”.

There’s another problem, too: While the Irish population has grown, Ireland’s medical schools have not. Trinity College, for example, is not producing vastly more people with medical degrees than it was in the year 2000. This means, very simply, that as demand grows from a growing population, and ever more free schemes increasing demand, the number of doctors is not growing.

And it also means that even if one were successful in attracting more doctors into general practice, the question remains: From where?

The answer is our hospitals, and other parts of the health service. You end up robbing Peter, to treat Paul.

A long term strategy to address this problem would have several components: First, you would invest in dramatically expanding the medical schools. We need more doctors, and that means we need more people training to become doctors. But if you did that tomorrow, the increase would not begin to show in the system for at least seven years – the length of time it takes to do a medical degree.

Second, rather than increasing demand, you would seek to reduce it: As Cormac Lucey suggested on my podcast last week, you would move towards online consultations, and remote access to doctors, to take some pressure off local GPs.

Third, you would seek to make being a GP more attractive, not less attractive. That probably means paying them even more than they currently earn – but it also means taking steps to reduce demand for their services, rather than increase it. In that context, is free GP care for under five year olds really wise? Does it not lead to people attending the doctor with a child who doesn’t really need to see the doctor? These are hard questions, but they need to be asked.

The problem, of course, is that our health service is not run in a way designed to deliver good health outcomes. It is run in a way designed to deliver votes.

Free GP care, in the short term, may well deliver some votes. But there is no reason – no reason at all – to believe that it will deliver a better health system.

In fact, I worry, and I think you should worry too, that it will just increase and intensify the already enormous pressures on a creaking GP system, by encouraging people who don’t really need to see a doctor to demand an appointment anyway. Just in case.

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