Vasco Da Gama 2015 Dublin The Effect of the Economic Crisis on the Irish Health System William Behan

Economic Crisis and Health Systems ResponsesThe Impact in Primary Care

The Irish Experience

William Behan

2nd Vasco Da Gama Movement Forum Plenary 1 February 2015

Dublin twitter@DrWilliamBehan

www.slideshare.net/DrWilliamBehan

Irish Model of General PracticeWhat is the total spend on General Practice?• Total public health spend: 8.5% GDP – includes some social care• (plus 2.5% GDP out of pocket/company spend) • 3.2% public spend €450m/€13,800m• 2.5% total health €450/€18,000m spend is on public GP• Possible total spend including private income 3.8% €700m/€18b

(Gov. data)

UK Comparison• UK total public and private spend on GP is £10.5b/£144b (7.3%)• UK total public spend on GP is £10b/£112b (8.8%)

W Behan, Vasco Da Gama, Dublin 2015

Irish Model of General PracticeHow Many GPs?• Total 3,800 GPs or 3,250 WTE GPs: Average 1 WTE GP per 1,400

population or 0.71/1,000 population• 2,470 have contracts to provide 24/7 services to public patients• 470 more GPs just have contracts to provide antenatal, post natal,

1^ immunisations and some screening• 1,800 Practice Nurses and approx 3,500 practice administrators

How Are GPs paid?• GPs are generally self employed and are small businesses• GP payments: 65% from state, 35% private • GP public payments: 77% capitation, 23% fee-per-item


Irish Model of General PracticeWho is entitled to what?Public Patients• Oldest, Poorest & Sickest 39% have Full Entitlement to free

healthcare• Next 3% lowest earners have free GP care – Most Equitable• The 42% of the population with free access to GP consume 2/3 all

consultationsPrivate patients• Free antenatal, post natal, 1^ immunisations and some screening• Low public hospital fees, €144 cap on monthly family

pharmaceutical spend but pay for everything else incl. GP fees


How have individuals been affected financially?• Increased Unemployment• Reduced Pay• Increased Income Tax and Private Health Insurance

Taxation (PHI costs increased greatly)• Self employed pay income tax at a higher rate than

employees on equivalent salary but do not have same benefits

• Private Pension contributions and funds now taxed• Social Welfare Benefits mostly protected• Education

What has been the impact in primary care?More patients have free access to their GP (1.31m -> 1.95m)

Public patients prescriptions incur a nominal charge

Some public patients are now being charged for GP services that were previously free (less ‘pro bono’ work)

Public servants pay and conditions have been protected due to grade inflation and increments for time in service

GPs have been exposed to disproportionate cuts

14,881

13,871

0

5,000

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25,000

2007 2008 2009 2010 2011 2012 2013†

€m

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Irish National Public Expenditure Changes 2007-13 (CSO) Social security and welfare

Health

Education

Transport and communication

Housing

National debt interest

Other community & socialservices


-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

2007 2008 2009 2010 2011 2012 2013 2014

National Total/GMS/Private Population

CSO Total Population @April

Mid-Year GMS Numbers

Private Population


1.39m1.96m

€450m

€432m €322 €308

€277€245 €236 €227 €220

0.0000

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100.0000

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300.0000

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500.0000

2008 2009 2010 2011 2012 2013* 2014*

GMS Patient Numbers, Total Payments to GPs and Payments per patient: 32% reduction 2008-2014

GMS Numbers (10,000s mid year number) Total GMS Payments to GPs (€Millions)

Payment per GMS patient (€)

Public Patients Public Fees*Estimated

W Behan, Vasco Da Gama, Dublin 2015Private Patients Private Fees

How were Irish GPs exposed to such great cuts relative to the rest of the health system? 10 years of fabricating reports- Culture of developing policy based on political agenda, then

manufacturing reports with statistics to support the policy- Exaggeration of GP public/private/total income- Minimisation of official GP numbers to provide a service supply

reason for “high GP fees”- Minimisation of GP Workload => reduce projected costs if planning

public GP services funded on a capitation basis- Under-reporting of Over 65s influenza immunisation rate:

measurement of quality of General Practice

How were Irish GPs exposed to such great cuts relative to the rest of the health system? - Commissioning reports from “independent sources” that

confirm overspend on GP by usage of corrupted data: 2012 PWC Medical Card Report (PCRS)and 2009 World Health Observatory Report (LSE & ESRI)

- Failure to provide timely accounts, correct mistakes in reports/oversight

- Failure of genuine regulation and accountability process - Public service capture and mission drift of regulatory bodies- Failure of media to expose unreliable reports poor policy

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2007 2008 2009 2010 2011# 2012## 2013* 2014*

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eOECD Self-Employed GPs Income per Average

National Wage

France

Germany

Ireland

Netherlands

United Kingdom

# Change in Irish methodology of calculating GP income## 2nd Change in Irish Methodology of calculating GP income* Forecast incomes including effect or Irish FEMPI 2013


0

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2007 2008 2009 2010 2011# 2012## 2013* 2014*

Pro

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eOECD Self-Employed GPs Income per Average

National Wage

France

Germany

Ireland

Netherlands

United Kingdom

# Change in Irish methodology of calculating GP income## 2nd Change in Irish Methodology of calculating GP income* Forecast incomes including effect or Irish FEMPI 2013


€-

€20,000

€40,000

€60,000

€80,000

€100,000

€120,000

€140,000

2008 2009 2010 2011 2012 2013 2014

Effect of cuts on Pre-Tax, Post Pension IncomeGeneral Practitioners vs HSE Staff c Increments

OECD 2012/HSE 2013 Data

GP Post-Pension


€-

€20,000

€40,000

€60,000

€80,000

€100,000

€120,000

€140,000

2008 2009 2010 2011 2012 2013 2014



GP Post-Pension

HSE LHO Manager Starting2008


€-

€20,000

€40,000

€60,000

€80,000

€100,000

€120,000

€140,000

2008 2009 2010 2011 2012 2013 2014



GP Post-Pension


(GRADE VIII) FINANCIALACCOUNTANT pay progress


€-

€20,000

€40,000

€60,000

€80,000

€100,000

€120,000

€140,000

2008 2009 2010 2011 2012 2013 2014

Effect of cuts on Pre-Tax, Post Pension IncomeGeneral Practitioners vs HSE Staff c Increments &

Promotions OECD 2012/HSE 2013 Data

GP Post-Pension


(GRADE VIII) FINANCIALACCOUNTANT pay progress

(GRADE VIII) FINANCIALACCOUNTANT promoted toLHO Manager


€0.00

€5,000.00

€10,000.00

€15,000.00

€20,000.00

€25,000.00

€30,000.00

€35,000.00

€40,000.00

€45,000.00

2008 2009 2010 2011 2012 2013 2014

Changes in GP and HSE Secretaries Funding 2008-2014

GP Secretarial subsidy (per year) — 3 or more years' experience IN 2008

Salary CLERICAL OFFICER GRADE III - YEAR 3 IN 2008

Salary GRADE IV (CLERICAL) YEAR 3 IN 2008

Salary CLERICAL OFFICER GRADE IV CLERICAL - YEAR 3 IN 2008


€0.00

€5,000.00

€10,000.00

€15,000.00

€20,000.00

€25,000.00

€30,000.00

€35,000.00

€40,000.00

€45,000.00

2008 2009 2010 2011 2012 2013 2014







€0.00

€5,000.00

€10,000.00

€15,000.00

€20,000.00

€25,000.00

€30,000.00

€35,000.00

€40,000.00

€45,000.00

2008 2009 2010 2011 2012 2013 2014







€0.00

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€20,000.00

€30,000.00

€40,000.00

€50,000.00

€60,000.00

€70,000.00

€80,000.00

2008 2009 2010 2011 2012 2013 2014



Total Cost: CLERICAL OFFICER GRADE III - YEAR 3 IN 2008

Total Cost: GRADE IV (CLERICAL) YEAR 3 IN 2008

Total Cost: CLERICAL OFFICER GRADE III - YEAR 3 IN 2008,PROMOTED IN 2013


€0.00

€10,000.00

€20,000.00

€30,000.00

€40,000.00

€50,000.00

€60,000.00

€70,000.00

€80,000.00

2008 2009 2010 2011 2012 2013 2014



Total Cost: CLERICAL OFFICER GRADE III - YEAR 3 IN 2008

Total Cost: GRADE IV (CLERICAL) YEAR 3 IN 2008

Total Cost: CLERICAL OFFICER GRADE III - YEAR 3 IN 2008,PROMOTED IN 2013


Irish Department of Health Claims • €3 billion have been taken out of the annual public

healthcare spend since 2008 (€16b->€13b)• €12 billion total health budget savings since 2008• €121 million annual saving in General Practice• €454 million total General Practice savings since 2008

Reality • Total savings have been eroded by increments for time

in service and grade inflation • Some efficiencies have been maintained• 10% total savings in health budget have come from GP• GP savings €220m p.a. or €960m in total since 2008

2009 2010 2011 2012 2013 2014 09-'14

Department of Health Figures (€millions)

-20.0 -38.0 -84.7 -84.7 -104.7 -121.7 -454.0

True Figures (€millions) -50.5 -75.4 -142.3 -162.4 -197.4 -219.8 -969.5

-1200.0

-1000.0

-800.0

-600.0

-400.0

-200.0

0.0€

mill

ion

s

Official Figures: Annual & Cumulative Fee Cuts to Irish General Practice 2009 - 2014


2009 2010 2011 2012 2013 2014 09-'14

Department of Health Figures (€millions)

-20.0 -38.0 -84.7 -84.7 -104.7 -121.7 -454.0

True Figures (€millions) -50.5 -75.4 -142.3 -162.4 -197.4 -219.8 -969.5

-1200.0

-1000.0

-800.0

-600.0

-400.0

-200.0

0.0

€m

illio

ns

Official and True Figures: Annual and Cumulative Fee Cuts to Irish General Practice 2009 - 2014



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Under 6s Attendance Rates

K Lynch predicted figure Gov. Survey GMS 1 yr recollection not incl. nurse

UK QRESEARCH Audit Under 6s IMJ GMS Audit Under 6s

Lifeways 2006 GMS Under 5s Audit Lifeways 2006 All Under 5s


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Audit

1 Year Recollection

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Adult Public Patients GP Attendance Rate

2001 CSO LIIS 2001 2007 CSO

2010 CSO Local Audit All 2008-2011 PCRS

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Adult Public Patients GP Attendance Rate

2001 CSO LIIS 2001 2007 CSO

2010 CSO Local Audit All 2008-2011 PCRS

1 Year Recollection

Audit or 2 Week Recollection

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Over 70s GP Attendance Rate

2001 CSO GP 2007 CSO GP 2010 CSO GP

Local Audit All NUI Galway 2011 2008 UK QRESEARCH

Economic Crisis and Health Systems ResponsesThe Impact in Irish Primary Care

• Smaller GP owned practices: more accessible, flexible, innovative, personalised service & more continuity of care

• More patients have free access => Increased equity of GP• However, prioritisation of political and administrative achievements over patient

centred care• ‘Opportunity in devastation’: Massive diversion of resources from privately run GP

into public servants salaries and property developers. Free GP @ < 4% budget• Massive drive to corporatise, increase bureaucracy, commoditise and fragment

care, removing clinicians from policy decisions• Irish GP has passed its tipping point and cannot cope • Since the last FEMPI in 2013 it has been difficult to fill GP posts• Extra demand on hospital services very evident in the last year• Has Irish General Practice resilience been totally exhausted?

Healthcare

Vasco Da Gama 2015 Dublin The Effect of the Economic Crisis on the Irish Health System William Behan