GP registration: important and simple

The new Government will be judged on how it implements its health commitments, particularly compulsory GP registration, Professor Andrew Murphy tells Meadhbh Monahan.

The ‘ecology’ of Irish health care cannot be measured accurately because “we don’t know who is registered with who.”

That’s according to Andrew Murphy, Foundation Chair of General Practice at NUI Galway. Murphy, who is also a GP in a semi-rural practice in Turloughmore, County Galway, says the Programme for Government’s commitment to make registration with a primary care team compulsory is “very welcome.”

The Fine Gael-Labour coalition, with GP James Reilly as Health Minister, has pledged to introduce universal primary care. This would see an end to GP fees, compulsory registration with a GP (not just for medical card holders), additional doctors, nurses and other primary care professionals, a new GP contract to incentivise the treatment of chronic illnesses, and the creation of an integrated system of primary and hospital care.

“I welcome the focus on primary care. Internationally, the evidence points out that one needs to have a strong primary care sector to try and deliver optimal health outcomes,” Murphy remarks.

A member of the expert group on resource allocation, which reported its suggestions for health reform last October, Murphy says the new Government is “clear in what they want to achieve so they can be judged by that.” He adds that health reform is “not just about how you raise the money, it’s about how you spend it.”

Compulsory registration is “an important simple thing to be done,” he adds.

Best practice

Scandinavian countries such as Norway, Sweden and Finland as well as Holland, the UK and Germany have GP registration systems that Ireland “would like to emulate.”

“All of them have the sense that everyone in the population is registered with a general practitioner,” Murphy states.

Currently, “only about one-third (31.9 per cent) of the population is registered.” These are the general medical services patients, who received a medical card following means-testing.

Because private health patients ‘pay-as- they-go’, they often have “a multiplicity of [GP] providers,” Murphy explains. “That means it’s been very difficult for practices to know who their patients are.”

This is particularly important for “preventative activities such as childhood immunisation, adult flu immunisations or trying to target patients with certain conditions such as diabetes or high blood pressure,” he adds.

In Scandinavia, GP practices are “immediately able to provide figures as regards their uptake for the MMR vaccine, and where there’s low uptake, look at the reasons why.”

Murphy says: “Often it’s more to do with the types of patients the practices have rather than the types of services being offered. But that hasn’t been possible in Ireland.”

He commends the work done by the Health Protection Surveillance Centre in providing figures, but says they are often difficult to interpret, whereas with registration, “it’s made very simple.”

Screening

Chronic disease management is going to be a key feature for health care over the foreseeable future, according to Murphy.

“That does depend on doing simple things well for lots of patients and if you don’t know who your patients are it’s very difficult to do those simple things.”

He points to diabetes, where, retinal screening has been introduced in the west of the country, “which is a really welcome development.”

Like GP registration, retinal screening is common in other countries but is only being rolled out in Ireland.

The screening of the eyes to check for any early changes due to diabetes is “particularly important because if you detect those early changes it’s possible to intervene early and prevent later development of blindness,” Murphy contends.

“Again it’s difficult for practices to reliably produce lists of patients with diabetes because they don’t know what their denominator is [who is registered with them],” he explains.

Often, the non-GMS patients “are most likely to receive benefit from interventions”. Because they don’t attend appointments, they are at higher risk. “So, if you have a proper register you can chase those patients,” Murphy believes.

Prior to Christmas, Murphy’s practice wrote 950 letters to patients who had registered there and who he felt should get the flu vaccine. Three came back from the families of patients who had since died but because they could have been registered with a “multiplicity of providers” Murphy’s practice had no way of knowing.

“It is more difficult for us in Ireland to target patients, so when we go through our lists we may be able to identify everyone at the age of 65. But for those who are not GMS patients, there is always a concern as to whether they are with us or other practices.”

However, “just because they haven’t attended for five years doesn’t mean they are no longer a patient; maybe they are very well. Or maybe they are attending another practice and would be irritated if you write out to them.”

According to Murphy, it is that “degree of uncertainty” which has “bedevilled attempts to try to act in a pro-active manner.”

In terms of implementing GP registration, Murphy believes it would be “fairly straight forward.”

He points out that some countries opt to provide incentives for registration such as reduced tax rates and increased benefits from private health insurance companies if you register with them.

Essentially, if people want to change health providers, it is “very important to have the ability to do that,” he clarifies.

Murphy hopes to see registration being implemented within the next two or three years. “Many countries are doing it so it’s not as if we are trying to invent a new wheel or anything,” he concludes.