A bitter pill to swallow

Family doctors and the Government are arguing over who controls GP charges. Picture / Hawke's Bay Today

You look at the magazines in the doctor's waiting room because you know you have to wait. There's no choice. But at least you know you will be inside the doctor's door fairly soon and you'll have 15 minutes to explain your problem. And you can expect the clinic to be well equipped.

These things are part of the consensus that is General Practice in New Zealand. But they are no longer assured, according to the doom-sayer logic of medical groups representing the GPs who care for 2 million New Zealanders, nearly half the population.

They say they are under threat from hooks the Government has stitched into its plan to spend nearly $112 million a year more on primary health care from July 1.

Dr Peter Foley, chairman of the General Practice Leaders' Forum, says the Government is trying to control the fees GPs charge patients.

He is leading a campaign to persuade GPs to reject most of the new money, but, as in all industrial relations fights, health patients will be the immediate losers by not getting the planned subsidies.

"If we agree to the Government setting our fees then we are handing over control of our businesses," Foley says. "We will not put our viability into the hands of bureaucrats."

But other GPs are comfortable with the Government's approach. An extra $111.6 million from taxpayers may seem a good thing, as it is intended to roughly halve the price paid by unsubsidised adults aged 45 to 64 to visit a GP - some 670,000 people.

This largesse is part of a seven-year, $2.2 billion Government plan to ensure "low or reduced cost" GP visits for all New Zealanders. The final instalment is scheduled for July next year, when subsidies will be offered for all adults aged 25 to 44.

In theory, this will help to catch many people's illnesses earlier, avoiding more costly hospital treatment. One of the first areas to benefit from the expanded subsidies, the Kidz First children's facility at Middlemore Hospital in South Auckland, reports a reduced rate of medical admissions.

Many people are already subsidised as their clinic serves an area of poverty or high Maori or Pacific population - and many other young and old people have access to subsidised care as the moves to state funding for the population are extended.

This is the second year in which negotiations between GP leaders and Government agencies have hit turbulence over the next slab of subsidies. Both times, the doctors have asserted that the state is illegitimately trying to interfere in their long-cherished "right" to set the fees.

Under the district health boards' proposed policy on patient fees, they would impose an "annual statement of reasonable fee increases".

Cases of general practices wishing to exceed that would be referred to a regional fees review committee with one member appointed by DHBs, one by primary health organisations (PHOs) and a chair appointed by those two members.

Rulings of the regional committees and appeal decisions by their combined chairs are binding.

The policy tries to force GPs to have their patient fees widely published, at least on their local health board's website or on their PHO's with a link to the health board's. This measure is less controversial than the alleged "fees control".

Many PHOs already disclose fees, but Foley's forum claims the plan is to create a national fees database, a claim the health boards deny.

He adds that the state's record on keeping up with health inflation is poor. While acknowledging that the July 1 funding includes a consumer's price index-linked increase - a rise of 3.34 per cent or $11.6 million to PHOs - "health goes up by about three times that".

A major cost on the horizon is the bid by primary health care nurses for pay rises to catch up with their public hospital colleagues, for which Health Minister Pete Hodgson refuses to provide extra money.

Unsubsidised adults pay on average $50 to see a GP, but up to $80 in some cities. The new subsidy will average $27.40 and the health boards expect all but 40c to be passed on to patients. This suggests patient fees will average $23, with a maximum of about $38.

"If they [the 21 boards] were funding the total price, they would have total control of general practice," Foley says. "They are not funding our total costs, therefore they cannot control our fees. They are funding to the level of just about 50 per cent of the average fee, only they are trying to have 100 per cent control.

"No business can operate that way. With inflation, their percentage will decrease over time, yet they want total control. It makes it very unattractive. It's hard enough to get young doctors to come in to general practice."

A long-serving North Shore GP agrees with Foley's dire predictions. "Your choices would be to go back to the 1950s, where you have a small surgery, no equipment, a receptionist and no nurse. Either that or GPs would decide to leave, or you could do what happens in areas of Britain - consultations of 5 to 7 minutes and try to see 60 to 70 people a day. You cannot maintain the sort of practice and excellence in medicine that requires a whole medical centre, ancillary staff, equipment and time."

His clinic spent $5400 on a wearable, 24-hour blood-pressure monitoring device, the kind of quality-improving investment Government fees control would endanger.

But the health boards dismiss talk of fees control and a resulting decline in general practice. They assert its viability will be enhanced by their proposal.

"Look at the 1990s, when GPs set their own fees," says their spokesman, Hawkes Bay board chief executive Chris Clarke. "Average GP incomes dropped dramatically. Since the roll-out of the Primary Health Care Strategy [in 2002] and the process of annual review of fees, we have seen GP incomes increasing significantly."

Research varies on the average GP pay packet. Waikato University and the Medical Assurance Society found it was around $140,000 for practice owners over the past two years, while a College of GPs survey that looked at all types of employment, including those on salaries, reported it at $93,000.

Clarke says GPs are entitled to set their own fees. But the state is paying $100 million in new subsidies - and half of GPs' income, on average, is from the Government - so the state is entitled to make sure the money is being spent as intended, on patients.

"We have a right and obligation to make sure that we can account to Government and to taxpayers."

Clarke agrees that most of the subsidies so far have gone to patients, not into GPs' pockets, but there is "some discomfort at the extreme high end of the fees". After the new subsidies for 18-24-year-olds last year, the median patient fee was $25, but they ranged from free to $48.25.

"Of concern are practices passing on the funding but raising their fees either just before the increase in subsidy date or afterwards. Another concern is complaints from patients that they are now being charged for extras - prescriptions, blood pressure measurements - that they were not charged for previously," says Clarke.

Many practices reduced fees and have kept them there but some have increased charges quickly and "eroded the benefit", Clarke says. One charged $38 before a new group of patients was subsidised, $30 afterwards, then $37 within two years.

New Zealand has around 3000 practising GPs, but their college predicts a future collapse in numbers if radical steps are not taken. Medical groups cite a host of reasons for the looming shortage, including red-tape, high medical student debt, too few students, lower pay than hospital specialists, an ageing GP workforce, and a rising clinical workload as hospitals tighten access to elective surgery.

Compounding this are shortages of locums, long hours and the rising number of female GPs legitimately driving demand for a better balance between work and home life.

Owning a practice, the traditional form of GP employment, is rapidly losing favour, yet the Government has shown no taste for taking over general practice, its investment costs and financial risks, except in isolated cases, such as the West Coast. College president Dr Jonathan Fox, part-owner of an east Auckland practice, considers himself lucky if he gets two weeks' holiday a year, or maybe three.

The North Shore doctor's experiences mirror college surveys. He spends about two hours each day on paper work, which includes reports for ACC, medical insurers and Work and Income. His clinic employs someone five days a week to handle administration, such as tax payments, compared with two half-days a week when he began practising 33 years ago.

"I'm lucky a lot of patients let me into their lives to share some of their problems and joys. That's what really makes general practice interesting. I didn't train to push paper around."

The Government pays for around 54 registrars to go through the college training programme each year - the National Government a decade ago cut the number to 50 from 100 - and two are privately funded at a cost of $70,000 each. The college, which turns away at least 50 applicants a year, wants the number of funded places increased. It is crunching the numbers before telling the state's Clinical Training Agency by how much.

While the college considers it an inferior form of training, another 56 doctors attend lectures and sit the exam but are not part of the programme. These numbers suggest strong demand to become a GP, but a widely quoted survey of first-year doctors found that just 9 per cent wanted to go into general practice. A further 40 per cent said student debts averaging $65,000 would force them into high-paid specialties.

The funding row has driven a wedge through primary health care, which Health Minister Pete Hodgson appears to be fostering. He is not commenting on the row, or on nurses' and specialists' pay talks.

In March, before the funding talks started, he outlined a carrot-and-stick approach. He hinted at "bonus payments" for services "really making a difference in their communities", and threatened that those who did not sign up by July 1 would miss out on the new money because he would re-direct the uncommitted funding.

Hodgson's office steered the Weekend Herald to PhoNZ, a group of primary health organisations which support the health boards' line and have 1 million enrolled patients.

This group is at odds with Foley's forum, which represents the Medical Association, the Rural GP Network, the college and the Independent Practitioner Association Council.

After addressing a meeting this week of 60 mainly west Auckland and North Shore GPs - many in PhoNZ-aligned organisations - Foley said it unanimously endorsed his position. "They were up in arms when they realised what their people are doing."

But Dr Clive Stone, chairman of the PhoNZ-linked HealthWEST primary health organisation in West Auckland, says members of the umbrella group are "mostly comfortable with the Government position".

HealthWEST chief executive Alan Greenslade accuses Foley of scaremongering and says more than half of HealthWEST members are comfortable with its stance.

"The right to set fees has not served general practice well, particularly where they serve populations of higher deprivation," says Stone.

"The idea of an advisory body that might set a benchmark for a fee increase has long had an appeal for the profession, which has seen Government subsidies wither in the face of inflation and medical cost increases."

Last year's row was largely settled on June 8, after the ministry backed down on the degree of fees disclosure required of clinics.

Whether the middle-aged patients of Foley's followers finally receive the new subsidies is unlikely to be decided until much closer to July 1.

He sees little sign of agreement being reached at the next talks on Tuesday.