HSE TO PROVIDE FREE GP CARE FOR UNDER 6'S
HSE TO PROVIDE FREE GP CARE FOR UNDER 6'S
A (fictional) Costing Exercise
Ministers Reilly & White seem determined to push through their vision of 'Free' GP Care for Under 6's without any regard to the concerns or expertise of the GPs tasked with delivering this care, 92-98% of whom have stated that they cannot sign the proposed contract as it is unworkable. So how will the HSE deliver free GP care?
How to deliver GP care without existing GP contractors?
We did a back-of-the-envelope calculation on what a HSE-led GP service for Under 6's might cost the country, without the involvement of existing GP contract holders. It is costed for all 420,000 children under 6 - 240,000 to get new free care, and 180,000 with current medical cards. (Health Act 2014 suggests that those aged 5 and under who currently have full medical cards may have to give them up for new doctor-visit style universal care, with potentially less benefits than currently - if the basket for UHI is as restrictive as suggested (eg may have to pay for some meds, dentist, eyes, A/E), but a shortage of facts exists).
SUMMARY OF POTENTIAL ANNUAL ESTIMATED COSTS IN a HSE-LED SYSTEM (details follow)
- HSE Medical salaries and employment costs: €120 million
- HSE Nursing salaries and employment costs: €15 million
- HSE Administrator salaries and employment costs: €121.25 million
- Premises rental (exclude HSE Primary Care Centres): €3.75 million
- General running costs and supplies: €14.55 million
- Total estimated annual costs: €274.55 million
- + Initial Premises fitout for non-PCCs (one-off cost): €22.5 million + €4.5 million = €27 million
- Total cost this year: €274.55 million + €27 million = €301.55million
BUT on the plus side, the HSE stand to save the €37 million that they had earmarked to give to existing GP contract holders to provide the same service. If they withdrew care of our existing Under-6 medical card patients as suggested this week (an illegal move as we have an existing contract) they may save another €28 million. Total savings = €65 million
So it would only cost them €301.55m - €65 million = €236.55 million.
In addition, parents who previously paid for their child to see the GP will now have more money in their pockets, which can be used elsewhere in the economy - so not a saving to the HSE, but a saving to families (until such time as they have to pay compulsory Universal Health Insurance to get seen in a previously-free public hospital).
This raises some questions, we think.
- Why do the Department of Health think GPs could provide unlimited care to all under-6s for €65 million if it would cost the HSE €301.55 million?
- Why does it cost so much for the HSE to run a healthcare service (about 5 times as much as GPs on this estimate)
GPs provide an extremely efficient and highly cost effective service, and are incentivised by being self-employed small business owners. General Practice has been pushed to breaking point by the FEMPI cuts - to the point where practices are closing down and GPs emigrating. GPs can certainly provide care far cheaper than the HSE, but we cannot do it for free. I have only listed a sample of the costs involved in running a practice, but GPs seem to be better value for money than the HSE across the board.
The Government are planning dramatic changes to how the Health Service is delivered in this country. The gross mis-spending in the hospitals and HSE in general needs to be addressed, so that finance can be transferred to General Practice who can provide far more services at a fraction of hospital costs. But we can't do it at a loss, or for no budget.
Changes like 'free' care for all, Universal Health Care, and moving much hospital care to the community take decades of planning (not 6 months), with GPs to the forefront of any programme. GPs want a better healthcare system for our patients - one without financial barriers. It won't happen this year. It will happen eventually and it will be a lot cheaper if GPs are involved in planning how to deliver quality healthcare efficiently.
DETAILS OF COSTING:
1. MEDICAL STAFF
420,000 kids (180,000 currently with medical card and new 240,000)
At an average of 6 visits p.a. = 2.52 million consults including lengthy 'Healthy Ireland' assessments.
(6 is a reasonable average based on recent data, some will visit less, some may visit 30-40 times/year).
GPs could manage average 30 consultations per day (150/week). HSE-led system would struggle to be this efficient and must include time for writing reports and having meetings, so more likely 20 children seen per doctor per day.
20 consults per day, 5 days/week = 100 consults per week.
2,520,000 consultations with 100 consults per HSE salaried GP per week = 25,200 weeks of doctors needed.
25,200 weeks/52 = 485 doctors.
Most GPs take less than 4 weeks per year off work (for financial and business continuity reasons, as they are self-employed), but if a doctor is offered the luxury of being a HSE employee, he/she would avail of the over-generous HSE leave entitlements, so maybe
5-6 weeks holidays p.a.
1-2 weeks study leave and
1-2 weeks sick leave,
=8 weeks off p.a. (conservative).
This fascinating document is worth a quick read, if your blood pressure can take it. No wonder the country is broke...Good for HSE employees, bad for taxpayers and anyone who values efficient work over holiday entitlements.
"The majority of health service grades or categories of staff have leave entitlements that are greater than the minimum as provided for in the Organisation of Working Time Act."
25,200 weeks/52 = 485 doctors BUT allow for average leave of 8 weeks so will need locums for leave cover = additional 88 doctors to provide locum cover.
44 available weeks per year per doctor.
25,200 weeks to be covered.
25,200/44 = need 573 doctors per year.
The majority of GPs leaving training schemes are female, so must allow for locum cover for paid maternity leave. Conservative estimate of another 50 doctors per year needed to provide this cover.
So need 573 + 50 = 623 full-time doctors. This doesn't factor in extra requirements for longer sick leave (as non-medical HSE employees are known to need) and the dozens of other leave scenarios in the attached document, so 623 doctors is still quite conservative.
The HSE have widely varying rates for doctor's salaries. Our Consultant colleagues are on very approximate salaries of anywhere from €95,000 to €222,000, according to HSE figures.
The most efficient solution for providing GP care to any population group, is to have GPs delivering the care. But if GPs don't sign up for this care, the HSE will have to provide the service themselves. It is likely they will attract plenty of GPs to a job on the well-known attractive HSE terms of employment. However, there is a manpower crisis.
If they fail to recruit the required number of 623 GPs (485 + 138 locums for leave cover) in Ireland, they may try recruiting from other countries. Many Irish GPs are currently emigrating due to the crisis, so they will find it particularly difficult to encourage GPs to leave security in another country to take a gamble on the Irish GP system. Recruiting costs have not been included in this costing.
If this also fails, they must consider hiring a number of Paediatricians and other specialists to cover all areas of expertise that a GP has. For the purposes of delivering 24-hour care GP care to just the Under-6s, the specialties most relevant would be: Paediatrics, Emergency Medicine, Dermatology, Public Health Medicine, Psychiatry, Surgery, with knowledge of bits of every other specialty required.
This would clearly be much more expensive (and inappropriate), however I have costed this on the presumption that the required number of GPs can be hired. Highly qualified specialists in the field of Generalist Medicine must be hired - GPs are the only doctors who can do all of the above. There is no pay grade for a GP employee of the HSE, as such a job doesn't exist.
So what might the HSE pay a GP to be an employee?
Minister Reilly says 1000 GMS patients are 'worth' €250,000 to a GP - implying that this would be what the GP earns for having that number of medical card patients. In reality, the average list size is 818 medical card patients, which costs the State €165,000 - this is the turnover, from which the GP has to pay the practice staff, premises, and all running costs (estimated at 64% of turnover on average) of providing 24-hour care, before trying to take a salary for themselves.
For argument's sake, let's pitch a fictitious GP salary considerably lower than that of an average Consultant colleague, yet considerably higher than the rapidly reducing income for GPs in Ireland, and more on a par with new entrant Consultants at around €116,000.
623 doctors x €116,000 = €72.268 million.
Add employer's PRSI, pension, indemnity and other employment costs. (gross employer cost of all theoretical HSE salaries has been estimated in this exercise to be about 150% of the employee's salary - we don't know if the true figure is higher or lower than this, feel free to correct this).
Approximate estimate for medical salaries: €120 million.
They will need to recruit trained practice nurses to help deliver GP care, perhaps one whole-time equivalent nurse for every 2-3 doctors.
200 senior nurses @ €50,000 = €10 million before employment costs as above (NB would need to be trained in General Practice), estimate for nursing costs: €15 million.
2 reception/secretarial staff (approx €30,000 + employment costs)
1 manager (maybe €100,000 + costs) per doctor = €160,000 + costs.
This is a significantly higher admin:doctor ratio than GP contract holders - in keeping with usual HSE practices (but much lower ratio and costs than their existing hospital averages). Approximately €250,000 per doctor (estimate).
485 doctors (not including locums) x €250,000 admin staff costs = €121.25 million
4. GENERAL RUNNING COSTS
These apply to all premises and GP practices, but will vary according to PCC set-up and other factors. The running costs are very varied, including: heat, light, electricity, cleaning (separate staff costs, and supplies), consumables, post, stationery, etc. Approximate cost per doctor = €30,000 x 485 doctors = €14.55 million
5. MEDICAL CENTRES
The HSE will have to provide appropriate accommodation for GP care for Under 6's in the community setting, and will need a good geographical spread. 485 GPs nationwide, some single-handed but some may co-locate. Let's assume that the HSE will use existing HSE primary care centres where possible, where they may not have either rent or building costs to deal with (GP contractors pay lots to rent there, but presumably the HSE don't). Optimistically, let's suppose half will be located in a PCC, so need privately-sourced premises for 240 GPs, some will co-locate so may only need 150 new GP premises.
150 small premises (good geographical spread), approx 1000sq ft at (HSE average) rent of €25 per sq foot = €25,000 p.a rent.
€3.75 million per annum in rent.
One-off fitout costs
Typical costs a GP faces when setting up: Fitout must be to the high standards as specified by the draft contract. Approximate conservative estimate of initial fitout costs to customise each non-HSE premises (including building costs, electrics, plumbing, paint, insulating; also must apply for planning permissions with associated legal, accounting and architectural costs) =
€150,000 per premises x 150 (conservative estimate) = €22.5 million to build the non-HSE infrastructure.
NB Delay in sourcing premises, applying for and obtaining planning permission = approximately 6 months. Building = approximately another 3 months
Computers, Furniture, etc
For each of the 150 non-PCC premises, and most of the HSE PCC premises, the HSE will need to purchase approximately 5 computers with printers; along with GP software for each computer, furniture and other fit-out for each room (office, surgery, reception, breastfeeding room, toilets, baby-changing facilities and waiting room).
Very approximate cost per premises: €15,000 x 300 (estimate) = €4.5 million (one-off cost with annual depreciation).
Obviously they will have saved a lot of money by using as many PCCs as they can, but as we all know, most of the country does not have access to one.6. OUT OF HOURS
Where possible, it is presumed that the HSE would use existing HSE funded out-of-hours services. However, not all GPs are members and not all of the country is covered by these. The HSE may find it difficult to join existing privately set up GP out of hours services. An alternative would be very costly. For the purposes of this exercise, I have not allowed for this scenario, but it may involve a large extra financial burden.
7. HOUSE CALLS & DRIVERS
The new draft contract provides for 24-hour care in the surgery, or the child's home. GP employees would need to have arrangements for how to support provision of housecalls on demand, eg a driver with car available for each geographical area. I haven't priced this, as it is possible the HSE have staff who could be redeployed without significant extra costs.
It may cost the HSE in the region of €300 million (give or take about €50 million) to provide a HSE-led GP service to all children aged 5 and under, something they have to provide if GPs don't sign the flawed contract. GPs are expected to provide enough infrastructure to provide the same care for €65 million.
Clearly this is a fictitious scenario, not costed by a health economist but by a front-line GP service. We would be interested to see other estimates of how to provide this service
What's clear is that GPs are best placed to provide GP care for operational, financial and clinical reasons, and that GP contractors are better value than the HSE for delivering GP services.
However, without adequate staff, infrastructure and resources any new service is doomed to chaos.