Ireland is one of the most expensive countries in Europe in which to access a general practitioner.
Whereas most of our neighbours ease the financial burden of seeing a GP, a majority of Irish people have to pay handsomely to see one.
A 2021 analysis found the average cost of a GP visit was €54; currently, consultation fees at surgeries in central Dublin vary between €65 and €80.
Compare this to Canada, Germany and the UK, where most GP visits are free, or France, where a typical fee is €7.50 and a yearly cap of €50 applies. In Norway, the co-payment is €16-34, with a yearly cap of €233.
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Free GP care for all has been official policy in Ireland since Sláintecare was adopted as the way forward for the health service more than five years ago. Progress has been slow, initially due to a lack of enthusiasm in government for Sláintecare and then because of the Covid-19 pandemic.
Now, however, the winds of change are blowing more strongly and the Department of Health has asked the Economic and Social Research Institute (ESRI) to cost the introduction of free GP care for the 56 per cent of the population who still do not have it.
At up to €880 million, the ESRI’s estimated price-tag seems affordable, even in the context of other demands for spending in health. The Government’s real decision will be to decide how fast to move in the direction of free GP care, especially given the shortage of doctors working in the community.
Different countries use different methods to reimburse GPs, each with their own advantages and disadvantages; some pay per service, while others pay per patient (capitation). There are also salaried GPs and, in some health services, performance payments.
At present, almost one-third of the population (32 per cent) has a medical card, which covers the cost of a GP visit and prescribed medications, and is also used as entitlement for other State servicea. The number of people with medical cards has dropped by 300,000 over the past decade, while the number of GP visit cards has increased. About 11 per cent of people have a GP visit card, which covers only the cost of a visit to the doctor.
The cost of a visit to the doctor is a deterrent for many people. A 2007 study found 19 per cent of patients in the Republic had a medical problem but had not consulted a doctor in the previous year due to cost; the equivalent figure in Northern Ireland, where GP visits are free, was less than 2 per cent.
Ireland uses the capitation system by paying GPs sums varying from €52 to €326 depending on the age of the patient. Capitation systems may prioritise long-term preventative healthcare, the ESRI report says, but may also encourage doctors to hold larger-sized patient lists in order to maximise income, which can result in a higher workload and shorter consultations.
The report looks at two possible ways of achieving the Sláintecare objective of universal healthcare by extending eligibility, either by age-group or by income level. The differences between the two approaches might not matter all that much if free GP care for all were to be implemented by 2026, but if the transition takes longer they could become more significant.
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Extending by age category is simple to implement and likely to result in a bigger take-up. But should wealthier people be able to avail of free GP care ahead of those with lower incomes, simply by dint of their age?
Giving something for free will inevitably increase demand. The extension of free GP care to under-sixes led to an increase in attendances at GP clinics of 21 per cent, one study found. Providing free GP care to 16 and 17-year-olds will increase GP visits by 38 per cent, another estimates.
On the other hand, and surprisingly perhaps, about 31 per cent of people eligible for a medical card do not avail of it, another study indicates. And even if the State does nothing, an additional 400,000 people will become eligible for free GP care by 2035, mostly because of the increasing proportion of the population aged over 70.
Ultimately, the pace of change will be dictated by the availability of GPs. Currently, family doctors say they are stretched to the limit. More than 700 are due to retire in the next five years. Same-day appointments are becoming hard to get. Many practices are not taking on new patients.
GP training places are being expanded - with a further 100 a year to be offered by 2026 - but as training lasts four years these doctors will not enter practise for some time. As the ESRI points out, if there are not enough doctors, access may still be limited by barriers such as long waits even after the introduction of universal free care.