1. 1 Paying for General Practice: the Past and the Future Dr. Martin White General Practitioner Nobber Co. Meath

2. 2 Clinical Background UCD Graduate, 1976 Vocationally Trained GP (Canada) Member of Colleges of General Practice of Canada, UK and Ireland 30 Years a Principal in a Rural Practice 3 Partners, Post Graduate Training and Research Practice, Computerised for 15 years

3. 3 Non Clinical Background Involved in a range of National and Local Negotiations on behalf of General Practice: 1988-2008 including GMS Contract Trustee of GMS Pension Fund (since 1979) Founding member of North East Doctor On Call (The first large Out of Hours Co-Op in Ireland) IT Tutor (Regional) HeartWatch Tutor (Regional)

4. 4 Paying for General Practice Services GP’ are: Self Employed Independent Contractors Canada: Universal Coverage Practice Registration – No Payment: Fee per Item of Service Out of Hours Service: Hourly Rate In Evolution

5. 5 Paying for General Practice Services (cont.) Ireland: Mixed: Private : Public approx 65 : 35 % Practice Registration – Partial Private : Fee per Item of Service Public : Pre 1989 GMS Contract: Fee per item of service 1989 GMS Contract: predominantly Capitation based system Universal Coverage: Fee per item of Service Maternity& InfantCare Childhood Vaccinations Cervical Screening Some Chronic Illness ( HeartWatch, DiabetesWatch) Out of Hours Service: Fee per item of Service

6. 6 Paying for General Practice Services (cont.) Holland Pre 2005 Mixed: Private/Public Now: Universal Coverage Social Insurance Practice Registration - Yes Payment: Mainly Fee per item of Service Partly Capitation Out of Hours Service: Hourly Rate The future for General Practice in Ireland No Change Extend GMS to all NHS Model (NI and UK) Universal Social Insurance

7. 7 Would GP's Support Dutch Model of Universal Health Insurance? Pro’s Nature of General Practice: Equality If similar UHI for Hospital System & Consultant Contracts Value Added : Universal Registration / Information Technology Gatekeeper Role Payment for Work done Out of Hours Structure & Payment GP's are by Nature Innovative/Adaptive/Pragmatic…pro change

8. 8 Would GP's Support Dutch Model of Universal Health Insurance? (cont.) Cons:  Funding / Payment including Staff Grants Pension and Locum Payments  Deficient Hospital and 2o. Care Systems  Deficient Primary Care Supports  Workload: Short Consultations  The Model: a) Simplistic & Single Fit:: Service Driven High Patient / Dr. Ratio b) Poor Fit for New Challenges: Chronic Illness Care, Mental Health etc. c) Demographic / Geographic Issues ? Lower Patient Satisfaction Rates Increased Bureaucracy

9. 9 Barriers to Change 1.Rebuilding Trust: De-Politicisation Replace Adhoc Policy and Crisis Negotiations (i.e.) Over 70's Medical Cards: Deregulation of GMS Contracts: Primary Care Teams with Vision and Planning, and Shared Memory a) Consensus: DOH IMO/ICGP b) Engagement: Negotiating Rights

10. 10 Barriers to Change (cont.) 2. Understanding GP's Role and Measurable Health Gains  Personal / Family Care Needs  Community Needs  Wider Goals: a.) Health Delivery Models and Integration b.) Relevant Quality and Health Gain Measurements c.) Targeting Resources Appropriately d.) Ownership / Co-Operation / Transparency e.) Independent Review Process and Remodelling

11. Will It Happen ? Consensus Leadership Bottom Up Not in Isolation Don’t Tear the Whole House Down Time Scale Yes !!

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14. 14 Any Questions? Thank you!