Editorial: Cheaper GP visits face crucial test

The Government likes to give the impression that it is steadily reducing the cost of seeing a doctor for everyone. It has grouped general practices into PHOs (primary health organisations) and aims to fund them for the number of people enrolled with the practice rather than the number they see. As a condition of their bulk funding, doctors are restricted in the fees they can charge each patient they treat. The scheme was introduced first for children and the elderly. But that was the easy part.

It was easy because if the cost of treating children and elderly patients exceeded the practice's funding for them, doctors could recover the cost from patients not yet covered by the scheme. And, indeed, most adults have found their GP's consultation fee has rocketed to $50 or more in recent years for exactly that reason.

But now the Government wants to extend its funding scheme to all remaining age groups. The Budget this month duly added another $112 million to health spending to bring people aged 45 to 64 into the scheme on July 1 and the Finance Minister boasted that from July next year all New Zealanders would be able to enjoy cheaper doctor visits. That was a brave call even before negotiations with PHOs broke down this week on the issue of fee restrictions. It was always predictable that the scheme would have to face the problem it faces now.

The idea that primary health care can be funded to keep people well rather than see them when they are sick is heart-warming in principle but financially risky for doctors in practice. It means they must carry the risk that patients will make more visits than the practice has been funded for. To cover for that doctors need to retain their right to charge whatever fee they find necessary. But then, the Government would run the risk that the extra $400 million it has committed for primary health subsidies might be pocketed by practitioners in a relatively low-paid branch of medicine.

This is the same conundrum that has confounded every Labour Government's hopes of lowering the cost of primary health care. Doctors have not been prepared to surrender their independent livelihoods. Helen Clark made an attempt to control GPs' fees as minister of health in the late 1980s, and failed. The Government she leads has a tendency to adopt schemes close to its heart before it has resolved their inherent problems. It has claimed to have lowered the cost of seeing a doctor ever since it came to office but it can no longer avoid the hard work.

Through its district health boards the Government is proposing to control GPs' fees this time by publishing an annual permissible increase. GPs who needed a higher increase would need to apply to a regional committee representing boards and PHOs, to which subsidised GPs must belong. Each practice's fees would be published on board or PHO websites.

The profession today is divided in its attitude to state control. Some are as reluctant as previous generations to surrender their financial independence but others seem to happily see themselves as part of the public health system. Practices are accustomed now to having state-paid nurses and carrying out fully funded public health programmes.

Few, though, want to surrender their discretion to recover unexpected or increasing costs. Medicine is constantly increasing the quality of the service it can offer and the rising costs of providing such care eclipse ordinary inflation. If GPs give up too much commercial independence it is their standard of service that will probably suffer in the long run. It is an old dilemma that this Government has not solved. Adults of working age have had to bear the cost of the scheme's uncertainties so far and they cannot count on fee relief yet.