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The GP negotiation challenge

The introduction of a new GP contract has been talked about for a long time. The current contract dates back to 1972, with changes made in 1989 adjusting the payment model from fee-per-item to a capitation system. In spite of all the changes that have occurred in general practice in the intervening decades, no progress was made on the issue until very recently.

The commitment of the Fine Gael/Labour coalition in 2011 to introduce free GP care brought the possibility of a new contract back on the political agenda. An impediment to the aim being achieved, however, was the insistence of the Competition Authority that the IMO cannot negotiate on behalf of its GP members on price.

The Competition’s Authority’s position had effectively halted the IMO’s ability to negotiate with the Government on behalf of its GP members. In 2013, a decision by the Organisation’s GP Committee to refrain from providing certain non-contracted services, including participation in primary care teams, community intervention teams and clinical programmes, in protest at proposed Government cuts to GP fees, caused the Competition Authority to bring a case against the IMO to the High Court.

The IMO refused to rescind its decision and counter-claimed against the Competition Authority. The High Court case was settled in May 2014 on the basis of certain undertakings being given by the IMO and Competition Authority to the court. The matter was struck out with no order as to costs.

The IMO agreed to not organise collective withdrawal of services or boycott as a means of influencing fees and also to advise its members that they must decide individually and not collectively whether to participate in the provision of publicly-funded GP services. The Competition Authority agreed that the IMO was entitled to consult with its members and discuss with the Minister for Health, HSE and Department of Health the scope, content and resources allocated to, and fee payable in respect of, publicly-funded contracts.

The Organisation was also entitled to communicate, discuss and express its opinions to its members at all stages of negotiations, including as regards the outcome of discussions. The IMO was entitled to express its opinion in relation to a contract but the GP must make an individual decision as to whether to accept or reject a contract.

For example, the IMO could state that in its view, a fee payable is not sufficient to provide a service but the GP must make an individual decision as to whether to provide that service. A Framework Agreement, separate to the competition case, was then agreed with the Department of Health and HSE. It allowed for negotiation on all aspects of publicly-funded contracts, including a third-party mechanism for fees, if necessary. The Framework Agreement was reached in light of the clarity brought to the competition aspects in the settlement agreement, and would not have been possible without it.

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Mr Val Moran, IMO Assistant Director of Industrial Relations

Under-sixes contract

As part of the conditions for negotiating the under-sixes contract, which was eventually chosen to be the first element of free GP care, a Memorandum of Understanding was agreed for a new overall GP contract.

“The decision was made by the GP Committee to enter into negotiations at that stage, provided that we would have a commitment to a wider contract negotiation,” IMO Assistant Director of Industrial Relations Mr Val Moran told the Medical Independent (MI).

“That was secured within the context of the under-sixes, that there would be a wider renegotiation of the GMS. We also had the first part of moving into the chronic care side of things, which is one of our main objectives with the introduction of the diabetic cycle of care, which was shortly after the under-sixes and the asthma cycle of care within the under-sixes contract. Following on from that, and moving on towards the overall contract discussions, within the Memorandum of Understanding, there are a number of points and issues which are to come under the agenda of the new contract.”

The first part of the discussion was the diabetic cycle of care for GMS patients. This was negotiated concurrently with the under-sixes and introduced in October 2015. As part of these discussions, the new part-time and flexible working arrangements GMS contract was also introduced. Negotiations then proceeded to rural practice issues and Special Items of Service.

The Rural Practice Support Framework was introduced on 1 May 2016 and a new agreement on Special Items of Service was also brought in on this date. Discussions are now taking place with regard to chronic disease management.

Last year, the then Minister of State for Primary Care Kathleen Lynch said she believed the contract could be finalised by summer 2016. Currently, a final agreement on the contract seems some way off. Mr Moran argued, however, that the diabetes cycle of care and rural practice framework will form part of the new contract, which he sees as being implemented in incremental stages, rather than simultaneously.

“We would hope once we agree a chronic disease package, you would eventually incorporate that as a schedule into the overall new GMS contract,” Mr Moran said.

“We would see once it is agreed — without necessarily having the parent contract, if you want to call it that, in place — that it would be incorporated into the contract once it is agreed, rather than waiting for everything to be agreed and having no movement in the interim.”

Groundwork

Negotiations can take a long time in respect of agreeing adequate resourcing and the level of service to be provided, he said.  “There is a lot of groundwork that goes into it, in terms of looking at the current system, in terms of looking at current capacity, potential workload and clinical standards as well.”

Chair of the IMO’s GP Committee Dr Padraig McGarry agreed with this assessment. The Longford GP said that given the last contract was negotiated in 1972, talks were never going to be completed in a matter of months.

“I never believed the contract would be done in a few months,” Dr McGarry said.

“I don’t believe that the Government would have the necessary resources to do that all in one go. If you have a 40-year-old contract and you are going to makes significant changes to it, you don’t do it at the drop of a hat; it has to be well-thought-out, it has to be fit-for-purpose.

“Yes, it has been slower than I would have liked, but what you want is something that is worthwhile, that is workable, and something that will stand the test of time. There is no point in putting something in and finding that this does not do what it is supposed to do. There is no point in us making a contract for 2016 if in 2020 this contract is no longer sustainable. You want to build something that is functional for a long period of time.”

Dr McGarry said that the run-up to the General Election and the Election itself did not help with the negotiations around the rural practice framework, which took longer to agree than expected, and held up progress with the new contract in general. He suggested that a time frame to achieve certain goals makes sense in order for sustained progress to be made in future talks with the HSE and the Department of Health.

NAGP CEO Mr Chris Goodey has disputed the contention that there has been progress in agreeing the new contract over the last year.

“If you think about it, we were told there was going to be a new GP contract in July 2016; we are now in July and no GP contract,” he told MI.

“We were told the GP care for under-sixes was going to be a temporary contract, so obviously that is not the case, as it is going to be automatically extended. It is of high importance that we get a new GP contract as quickly as possible.”

However, he said further progress on the contract is unlikely before November, around which time the Dáil Committee on the Future of Healthcare is due to report. This committee is charged with developing a 10-year health strategy and was proposed by the NAGP, amongst others.

Future talks

According to Mr Goodey, the NAGP has been encouraged by comments from Minister for Health Simon Harris that he is considering options around the negotiation process, including the possibility of broader consultations with stakeholders. Mr Goodey said the NAGP is willing to work alongside the IMO in future talks.

“We have a formula in terms of what needs to be in the new contract and we are keen to work with the IMO in terms of making that happen,” he said.

Dr McGarry said that it is not up to the IMO as to whether the NAGP is included in future negotiations on the contract. The IMO is due to resume talks with health management on chronic disease in September. Resourcing and staffing of general practice will form an essential part of discussions. The union has contracted University College Cork health economist Dr Brendan McElroy PhD to analyse the results of a survey it conducted of its GP members on chronic disease workloads.

The results of the survey will be vital in informing the IMO about the different models of chronic disease management that could be employed in the new contract. Mr McGarry said that a multi-morbidity model is the one most likely to be adopted, although this decision has yet to be finalised. The HSE is also conducting its own preparatory work on a chronic disease management model.

Dr McGarry said the IMO is well aware of the importance in ensuring the negotiations are a success.

“What it will have to mean is that general practice is put back on a viable footing, that it is put on a footing that will attract GPs back into it as a career, because at the moment a lot of them would like to go into general practice but I think they are somewhat afraid of the insecurity of it,” he said.

“It is like anything — if you don’t make it attractive, people won’t necessarily go there and if they have got alternatives, and the reality is that Irish-trained GPs are very much sought after. If they are being offered a much more attractive proposition, they will go. You have to reverse that if you want to get to them to stay.”

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