Editorial: Easing the pressure on GP fees

With very little fanfare, one of this country's oldest political dilemmas may have been solved this week. Doctors in general practice have come to an agreement with the district health boards that allows GPs to charge a reasonable fee when the Government's primary health subsidies are extended to everyone aged 45 and older from July 1.

The programme already covers those aged 65 and over or younger than 25. The inclusion of the 45-to-64 age group this year will be followed by the 25- to 44-year-olds from July next year, completing the population coverage, but this year's increment presented the programme with its crucial test. It was simple enough to bring the dependent demographic groups into the scheme; doctors are well accustomed to giving fee concessions to children, students and pensioners. The working age population is a different story, particularly older income earners.

People aged 45 to 64 are generally in their peak earning years. They no longer have young families and they are also likely to be visiting the doctor a little more than they did in their younger adulthood. If the GPs found they were losing money attending to the Government's subsidised groups, it has been their 45- to 64-year-old patients who seemed most able to bear the cost of keeping the practice solvent. The risk of losing money on the subsidised groups is the reason many GPs have raised their fee for adult patients to around $50 a visit since the Government's primary health strategy began.

This year brought the crunch. If the scheme was extended to the older working age bracket on the same terms, GPs would lose their financial safety valve. Their representatives have been bargaining hard to retain the utmost freedom to set fees on top of the subsidy. The district health boards, on the Government's behalf, have been almost as determined to see that the subsidy can lower the cost of seeing a doctor by as much as the Government wants to claim.

The deal done this week, barely 10 days before the July 1 deadline, looks on balance to be a victory for the doctors. They have agreed to independent reviews of fee increases considered by district health boards to be unreasonable. In other words, they can probably continue to set fees, fairly safe in the assumption that district health boards are likely to act only in exceptional cases and perhaps only in the unlikely event that patients complain. Patients who believe they are being overcharged are more likely to quietly change doctors than attempt to initiate a fee review.

The Government, of course, could seek a more general fee review if it found the extra $400 million it will have put into patient subsidies had not appreciably reduced the cost of seeing a doctor. But by the time that became apparent the Government will probably have gone and its successor might be more inclined to review the wisdom of the whole scheme. The funding system is an incentive for practices to keep a certain number of people well rather than be paid to see them when they are sick. But it puts practices under the risk that patients will seek more attention than the practice has bargained for.

For the moment, though, the Government can claim a breakthrough on a problem that has dogged the Labour Party's health dreams since the inception of social security. It is still a long way from delivering free health care for all but it has got GPs to compromise their fee-setting right, at least in principle. Next year the last age group is likely to be included on the terms agreed this week. It is a significant moment, even though it probably will turn out in practice that doctors are as free as they should be to run their business as they think best.