Topical Issues Debate Wednesday 6th June: General Practitioner Services

Deputy Anthony Lawlor: I thank the Ceann Comhairle for giving me the opportunity to raise this issue and the Minister of State for being in attendance. The issue I wish to raise was brought to my attention in my clinics a few weeks ago by an elderly couple who explained to me that they were both in need of regular blood tests because one of them was on warfarin which required regular blood testing, while the other needed blood tests owing to a diagnosis. They told me that they both had medical cards and that they were being charged by different GPs for having the tests done. They were both visibly upset when they told me this because they believed they should not be charged for this facility as they both had medical cards.

When they left the office, we conducted some research. We rang a number of GPs in Kildare and found out that while a few doctors were not charging patients for this facility, a number were charging between €20 and €45, even though it should be provided free of charge. Doctors claimed they were charging for the service because it was taking time for them to carry out blood tests. The health correspondent of the Irish Independent, Eilish O’Regan, wrote than in some cases it could take up to 20 minutes to carry out a blood test. Was blood being taken from a stone? Other reasons for charging included the cost of transporting blood samples to laboratories. If a doctor takes five blood samples per day and is charging €40 per patient, for €200 I would pick up the blood samples on my bicycle and bring them to the laboratory. It seems ridiculous.

I wrote to the HSE to confirm if the practice of charging for these services was allowed. It sent me a letter on 17 May. It stated:

It is a general practitioner’s contractual responsibility to provide proper and necessary treatment to eligible persons. If part of that proper and necessary treatment, as referred to above, includes routine phlebotomy, the GP must provide that service free of charge under the terms of his or her contract. The HSE has written to GP contract holders and clarified the position on this matter, and has also communicated the position to the Irish Medical Organisation.

I have also a letter the HSE sent on 20 June 2011 which clearly states GPs should not be charging medical card holders for these services. There is a response on MediLearning.ie from Dr. Mary Gray, the spokesperson for GPs on the IMO committee. She stated the following:

This position was notified to the Department of Health and Children in 2009 and 2010 in IMO submissions on the Financial Emergency Measures in the Public Interest Act. The matter was further clarified in correspondence with the Minister for Health and Children €¦ It was not a matter of dispute between the parties and we therefore strongly reject any suggestion that GPs are acting outside of the terms of the GMS contract.

Therefore, the IMO believes doctors should charge for the service, while the HSE believes they should not. People are at loggerheads and there seems to be no solution forthcoming either from the HSE or the IMO. This has been ongoing since 2009. At the end of the day, do we expect patients who have built a long-term relationship with their doctors to ring the HSE and make a complaint? I find it very difficult to believe. The direction should come from the HSE. Those who are suffering are the sick and the elderly, the people for whom we have to care.

Minister of State at the Department of Health (Deputy Róisín Shortall): I thank the Deputy for raising this issue because it has come up from time to time in the last year in the House. I am glad to have the opportunity to clarify the position on it.

The current general medical services GP capitation contract was introduced in 1989 and is based on a diagnosis and treatment model. Section 11 of the contract provides that the medical practitioner shall provide for eligible persons, on behalf of the Health Service Executive, all proper and necessary treatment of a kind usually undertaken by a general practitioner and not requiring special skill or experience of a degree or kind which general practitioners cannot reasonably be expected to possess. GPs who hold GMS contracts with the HSE must not seek or accept money from medical card or GP visit card holders for services covered under the GMS contract. In circumstances where the taking of blood is necessary either to assist in the process of diagnosing a patient, or monitor a diagnosed condition, the GP may not charge the patient if he or she is eligible for free GMS services. I am very disappointed that a minority of GPs have chosen to charge patients whom the State has deemed to be unable to meet the cost of medical services.

This issue was first raised last year. At my request, the HSE wrote to all GMS GPs on 21 June 2011, reminding them of their obligations under their contract in respect of services such as phlebotomy and advised them that charges should not be applied for such services. The HSE also pointed out that in many GP surgeries it was the practice nurse who took blood samples and that the HSE significantly subsidised the cost of employing such practice nurses. I will continue to monitor the situation closely to ensure this unacceptable practice is brought to an end.

The HSE is encouraging eligible patients who believe they have been inappropriately charged by a GP for routine phlebotomy services to seek a refund from the GP in question. Alternatively, they may wish to follow up with the HSE and the matter will be fully investigated. Formal complaints will be dealt with through the HSE’s consumer affairs service. In a number of cases to date GPs have reimbursed their patients following receipt of correspondence from the HSE. It is appreciated that because of the nature of the GP-patient relationship, it may be difficult for patients to make such complaints. I fully appreciate this. Where public representatives are made aware of GPs charging GMS patients in error, they may wish to notify the HSE directly.

It is worth reiterating that the programme for Government provides for the introduction of a new GMS contract, with an increased emphasis on the management of chronic conditions such as diabetes and cardiovascular conditions. It is envisaged that the new contract, when finalised, will focus on prevention and include a requirement for GPs to provide care as part of integrated multidisciplinary primary care teams. Officials in my Department are in consultations with the HSE with a view to drawing up a new contract. The appropriate arrangements for phlebotomy services will be considered as part of the new contract. I again thank the Deputy for raising the matter.

Deputy Anthony Lawlor: I thank the Minister of State for her reply. I note that she has raised this matter on a number of occasions, but the sad fact is that the practice continues. The Minister of State said it is being continued by a minority of GPs. I can assure her that the majority of GPs are charging medical card holders for blood tests.

Should a test case be taken against a GP? I cite the vice-president of the Irish Medical Organisation, Dr. Ronan Boland and Dr. Mary Gray, who has said that the IMO received legal advice that routine blood testing was not part of their contract. She said if any action were taken against a GP the IMO believed it would be on solid legal ground to defend it. I believe we should take a test case against one of these doctors and establish whether they have a legal right to charge for this service.

Do we need to introduce legislation to ensure the HSE contract requires doctors not to charge for blood tests? Will the new contract referred to by the Minister of State ensure all loopholes such as this are closed? Patients who are scared and worried do not want to have a conflict with their GPs with whom they have built up long and trusting relationships. Public representatives such as myself do not want to report GPs on behalf of constituents because this can also lead to a breakdown in trust. We must ensure this does not happen in the future.

Deputy Róisín Shortall: I am disappointed to hear the problem is widespread in Deputy Lawlor’s constituency, and I do not doubt him for a moment. I would encourage the Deputy to take action and to report the names of the GPs who are charging, when they should not be doing so, to the HSE. If he has a concern about doing that, I would be happy to act as a go-between and to accept reports from him on GPs who have been found to have engaged in this practice.

Following the action taken last year, a number of patients have been reimbursed. I will now give serious consideration to sending a reminder letter to GPs. I thought the problem had been stemmed. If that is not the case, I am happy to pursue the matter. If Deputy Lawlor will forward me the information he has, I will take action on it.