William behan analysis 2018 dper and tcd 2017 reports on general practice

‘Government Expenditure on General Practice
Spending Review 2018’
and
‘A Future Together Building a Better GP and Primary
Care Service’ 2017:
A Critical Analysis
William Behan February 2019
Non-Peer Review Working Paper
@DrWilliamBehan
Walkinstown Primary Care Centre

Critical Analysis of the 2018 DPER and 2017 TCD Reports on General Practice February 2019
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Contents
SUMMARY...................................................................................................................................... 3
1. The public spend on general practice............................................................................................ 3
2. The private spend on general practice .......................................................................................... 3
3. Points 1. and 2. deliver a total spend on Irish general practice..................................................... 4
4. Comparison of the Irish annual payment per GMS patient and UK NHS payment..................... 5
5. The mis-calculation of the UK nurse activity rates relative to Irish GP nurse workload ............. 6
6. The extrapolated savings benefits from utilising nurse triage is unreliable.................................. 6
7. Suggesting a lack of proof of the efficiency of Irish general practice is a result of the ignorance
of the authors................................................................................................................................. 6
WHAT IS THE TOTAL HEALTH SPEND ON IRISH GENERAL PRACTICE? ........................ 8
1. GP PUBLIC PAYMENTS........................................................................................................ 8
Table 1. HSE payments to General Practitioners for GMS services alone............................... 8
Table 2. HSE payments to General Practitioners for non-GMS (universal) services............... 8
Table 3. Non-Clinical/Non-HSE Public GP Payments............................................................. 9
Table 4. GP Co-operative Costings .......................................................................................... 9
Table 5. Total Clinical and Non-Clinical Public GP Payments................................................ 9
Table 6. System of Health Accounts payments to Medical Practices (HP.3.1) 2013-2016 ... 10
Table 7. GMS: Summary of Statistical Information for 2013 – 2017 calculation of PCRS
payments per person ............................................................................................................... 11
Table 8. This Reports Calculation of GMS + Non-GMS payments per GMS patient ........... 12
2. GP PRIVATE PAYMENTS................................................................................................... 13
Table 9. Household Budget Survey Data. HS012: Average Weekly Household Expenditure
................................................................................................................................................. 13
Table 10a. Systems of Health Accounts Household Out-Of-Pocket Payments for Ambulatory
Healthcare Providers............................................................................................................... 15
Table 10b. SHA06 Health Care Payment Schemes for Medical Practices (HP.3.1).............. 15
3. TOTAL GP PAYMENTS....................................................................................................... 16
Table 11. Total GP Payments in the 3 Reports Aggregated and Presented as a Percentage of
the Total Current/Current + Capital Health Budget................................................................ 17
Table 12a. OECD Discription of Ambulatory Health Care Providers (ICHA-HP) HP.3.1.1-3
(Doctors) ................................................................................................................................. 18
Table 12b. OECD and SHA Taxonomic Hierarchy of Ambulatory Health Care Providers
(ICHA-HP).............................................................................................................................. 19
Table 13. Comparison of Household Budget Survey and System of Health Accounts of
General Practice Out of Pocket and Health Insurance Income............................................... 19
4. COMPARISON OF THE ANNUAL PAYMENTS PER PATIENT: IRISH GMS/ALL
PATIENTS vs. UK NHS PATIENTS ............................................................................................ 20

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Table 14a. Comparison of Irish & UK GP Payments per Head of National Population
Depending on Data Source ..................................................................................................... 21
Table 14b. OECD Stat Government Expenditure on Medical Practices 2011-2016 Ireland and
UK........................................................................................................................................... 21
5. THE DIFFERENCE BETWEEN UK AND IRISH PRACTICE NURSE WORKLOAD..... 23
Table 15a. The Difference Between Irish and UK GP Practice Nurse Workload as a % of
Total Clinical Visits................................................................................................................ 24
Chart 1. Trends in Irish and Northern Irish GP Nurse Clinical Visits as a Percentage of the
Total Clinical Visits................................................................................................................ 24
6. DOES NURSE TRIAGE IN GENERAL PRACTICE RESULT IN SAVINGS FOR THE
OVERALL CYCLE OF CARE? .................................................................................................... 25
7. PROOF OF THE EFFICIENCY OF IRISH GENERAL PRACTICE ................................... 26
CONCLUSION............................................................................................................................... 28
REFERENCES ............................................................................................................................... 29

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SUMMARY
The Department of Public Expenditure October 2018 Spending Review; Government Expenditure
on General Practice by Stephen Brophy and Donal Lynch of the Labour Market & Enterprise
Policy Division (DPER Report) have 7 main themes. Many of the deductions made in these
reports would not correlate with an assessment of the best available evidence. Critical analysis
of this identifies errors in GP funding that were similar to those errors previously published in the
2017 Trinity College Dublin report ‘A Future Together Building a Better GP and Primary Care
Service’ by Tom O’Dowd, Jo-Hanna Ivers and Deirdre Handy. This document is an elaboration of
a twitter thread originally published on-line in October 2018.i
1. The public spend on general practice.
The DPER figure of €586 million Health Service Executive (HSE) spend on general practice
in 2016 comes from the SHA Government/compulsory schemes category. This System of
Health Accounts (SHA) figure already includes direct payments to General Practice (GP)
for universal services such as childhood vaccinations, GP training, and indirect GP
payments for out of hours services. This figure is very similar to this report’s
independent calculation of €590 million for the same basket of services. It appears to not
include the funding for the Maternity and Infant Scheme. Total government funding of
general practice including all direct and indirect HSE payments to general practice
appears to be €605 million using this reports calculation which is similar to the DPER
figure of €601 million if maternity payments are included. This report does not calculate
any implied health insurance subsidy of general practice.
The DPER report clearly includes single discipline consultant clinic expenditure, tax
rebates relating to this non-GP activity and associated health insurance cost. There is
also an element of “double dipping” on tax rebates when claiming that this is a loss to
Revenue but not including the tax revenue returned from GPs as a result of this income.
The Trinity College Dublin (TCD) report calculation of €543 million HSE spend on GP GMS
services in 2014 is not itemised. That figure is €29 million more than this reports
calculation of the combined GMS and universal HSE payments for that year.
2. The private spend on general practice.
This reports calculation of total GP private income including health insurance subsidies
but excluding private hospital consultants in the community, minor injuries clinics and
community intervention teams provides a figure of €203 million for 2016 and €200
million for 2014 for total GP private clinical income.

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The DPER report 2016 figure of €351 million comes from the processed and aggregated
System of Health Accounts (SHA) household out-of-pocket payment (OOP) SHA06 HP.3.1
figures. The SHA SHA06 HP.3.1 figure comes from a combination of Central Statistics
Office (CSO) Household Budget Survey (HBS) data, Department of Revenue data, HSE
data and secondary analysis of the data. The final figure includes GP and psychiatry
along with single discipline consultant medical clinics inflating the overall GP cost. It
also has a knock-on effect on the calculation of health insurance and revenue
transfers referred to in point 1 above.
The Organisation for Economic Co-operation and Development (OECD) Classification of
health care providers (ICHA-HP) also uses the code HP.3.1 for medical practices which
comprises both offices of HP.3.1.1 general medical practitioners (general/family
practitioner in private offices even if they are on the specialist registrar in some
countries) and offices of all medical specialists HP.3.1.2 (Psychiatrists) and HP.3.1.3 (Non-
psychiatrists)(Occupation Code 2210 ISCO-08, ISCED-97 level 5 and 6) who are operating
independently of hospitals or HMO-type medical centres.
The €351 million figure is €148 million more than the calculation in this report which is
derived from the CSO HBS total out-of-pocket expenditure on general practice plus a
figure of 10% private health insurance co-payments which comes from The Irish
LongituDinal Study on Ageing (TILDA) data.
The TCD report uses a similar figure to the DPER report for its 2014 private GP spend.
This appears to aggregate elements of HP.3.1.1 and HP.3.4 and HP.3.5 data to derive a
figure a total annual GP spend. However, the figure of €315.5 million in the TCD report
for private GP spend is the same as the average of the 2013 and 2014 SHA 3.1 out-of-
pocket medical expenditure figures, which is €116 million more than the calculation in
this report.
3. Points 1. and 2. deliver a total spend on Irish general practice.
The DPER report has a figure of €994 million total spend on Irish general practice in 2016
which includes public direct and indirect spend, private OOP spend and social welfare
income. This inflates the total GP spend by €167 million compared to the calculation in
this report, or €187 million if Social Welfare income is not included in the calculation.
The DPER implies 5% of the total current (not capital) health budget is spent on Irish
general practice.
The TCD Report refers to a 2014 calculation of 4.5% total spend on Irish general practice
as a proportion of the total health spend. The TCD Report calculate the total 2014 GP
spend to be €858.6 million when this report calculates the total public and private GP
2014 spend to be €713.8 million, or €733.8 million if Social Welfare income is included.

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Both the DPER and TCD reports figures over reflect the GP spend as a proportion of the
total health spend on general practice by
o Inflating the GP private out of pocket spend
o Not highlighting that the included GP superannuation spend is a real time spend
when the public service pensions are on a ‘pay as you go’ basis with a significant
proportion of the pension liability of current HSE staff deferred to a future date
after they have retired. This has the effect of reducing the HSE current health
spend on staff.
o Only using the health current spend figure and not including the capital spend
when general practice has no direct access to this capital fund.
The inflation of the total GP spend in the DPER Report results in a total spend
approaching 5% of the total health budget. A closer analysis of all the available data
results in a GP spend of less than 4% of the total health budget, and a lower figure if the
total capital spend plus future pension costs is also included in the calculation. The TCD
Report figure of 4.5% total health spend on Irish general practice is similarly biased
upwards by about 20% from a 2014 figure of 3.7% total health spend on general practice.
4. Comparison of the Irish annual payment per GMS patient and UK NHS payment
is not just flawed because
o The Irish patients covered are the youngest, oldest, poorest and sickest 43% of
the national population which are all features associated with a higher
attendance rate and the comparison is the full UK population.
o It is also flawed because it includes all GMS plus some non-GMS funding when
trying to calculate the Irish GP figures, including out of hours, IT and capital costs,
but the UK figure only uses the UK GP Earnings and Expenses data which does not
include indirect payments to general practice for the provision of the same
service which can be found in the UK Investment in General Practice reports.
o The Irish GMS population in reality is larger than the official GMS population used
to provide the denominator when calculating GP income per patient. Many Irish
GMS patients have their medical card capitation payments to their GP stopped
on bureaucratic grounds and also GPs covering European E111 patients is not
included. The UK NHS population is a lot larger than the national population
survey figure because the NHS population includes UK citizens living or travelling
abroad are missed in the national census. The UK national census does not count
non-national citizens who are residing in the UK less then 12 months but might
still attend the GP services.
o If the total public and private GP payments per head of population for 2016 were
compared, the Irish figure of €170.35 produced by this report compares very
favourably in terms of value to the UK payment of £182.72 (€203.03 - €261.03)
public and private spend per head of population.

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5. The mis-calculation of the UK nurse activity rates relative to Irish GP nurse
workload has been because
o The UK Qresearch nurse visiting data includes what would be considered public
health nurse data in Ireland with regular GP nurse activity.
o The Connolly et al. (2018) cherry picking of 2006 Northern Ireland nurse activity
data suggests that Irish practice nurses are utilised less than ROI nurses. More
substantial Northern Ireland research on GP and GP nurse workload based on
repeated annual audits from 2003 to 2014 of 35 practices reports that nurses
provide 29% of the clinical consultations in general practice. This is very similar to
Irish 2014-2018 data with the Healthy Ireland average figure of 26% or the Health
Interview Survey figure of 32% all clinical consultations in general practice being
provided by the nurse.ii
o It should also be noted that the lower Healthy Ireland GP nurse data is used
instead of the CSO Health Interview Survey figures.
6. The extrapolated savings benefits from utilising nurse triage is unreliable. It is an
assumption resulting from a single 2007 paper by Lordoniii is subject to many caveats.
Nor have its results been reproduced by Cochrane systematic review or more recent
research. It seems to have been more an abstract mathematical exercise with no
appreciation of the ‘total cycle of care. The “efficiency value” for an OOH co-op seems to
be assessed in terms of lower payroll costs and decreased time between co-op contact
and clinical consultation, with the assumption that all care is homogenous. More recent
analysis has shown nurse triage to be associated with an increased follow-up attendance
rate compared to GP triage.
7. Suggesting a lack of proof of the efficiency of Irish general practice is a result of
the ignorance of the authors. It is also an exposure of the poorly informed nature of
the health economics community narrative on this topic rather than a review of the
available evidence.
It does not consider the 2/3rd
ED attendance rate per capita in Ireland compared to English ED
activity as a surrogate measure of good Irish GP performance.iv,v The greater continuity of care
provided by self-employed GPs in Ireland compared to the UK has been shown to be associated
with reduced unnecessary hospital admissions. The authors the DPER Report misinterpret UK
and Australian data on the proportion of time spent by GPs on non-clinical activities when
comparing the statistics to Irish data. They would have been better served referencing the more
reliable UK National GP Worklife Survey that was first run in 2005 with the 9th
survey run in 2017.
This indicated that 61% of a GPs’ time was devoted to direct patient care, which is similar to Irish
data

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WHAT IS THE TOTAL HEALTH SPEND ON IRISH GENERAL PRACTICE?
Irish General Practice is funded from both public and private sources.
1. GP PUBLIC PAYMENTS
Most of the itemised GP HSE payments can be found in the Primary Care Reimbursement Service
(PCRS) Statistical Analysis of Claims and Payments with the balance of the clinical payments
being available in the HSE Annual Reports and Financial Statementsvi,vii. Most of the public
funding is direct payment for GMS patients’ care (Table 1.) Some public payments for GP
provided healthcare covers all the population including non-GMS patients. These universal
services include ante-natal and post-natal care, primary immunisation up until school going age,
cervical screening and methadone prescribing. (Table 2.)
Table 1. HSE payments to General Practitioners for GMS services alone
2016 2014
Table 13 GMS: Payments to General Practitioners 518,166,985 428,340,870
Benefits to retired DMOs and their dependants 3,000,931 3,695,221
Former District Medical Officers 1,341,918 1,341,918
Total GMS payments to GPs minus Non-GP
expenses
€513,824,136 €423,303,731
Table 2. HSE payments to General Practitioners for non-GMS (universal) services
2016 2014
Irish Family Planning Association (IFPA)v 1,259,000 1,240,000
Primary Childhood Immunisation Scheme 6,925,243 7,487,715
Health (Amendment) Act 1996 188,666 180,248
Heartwatch 981,986 1,019,801
National Cancer Screening Service 12,140,908 12,596,752
Methadone Treatment Scheme 7,729,027 7,322,652
Maternity and Infant Care Scheme (Est.) 14,700,000 15,400,000
Non-GMS Public GP Income € 43,924,830 € 45,347,168
Some of the cost of providing post graduate GP training in the community could be considered a
direct payment to GPs which indirectly increases the capacity to provide care in the community.
It can be divided into payments for training scheme staff and GP trainers as well as salaried for
GP training scheme registrars who spend two of the four years of the training schemes working
in general practice. Social welfare payments to GPs for providing certification is from a non-
health source to provide an administrative duty. (Table 3.) Grants to GP cooperatives to provide
out of hours care would be considered an indirect payment to GPs to provide medical care.
These payments can be found in the HSE Annual Reports and Financial Statements (Table 4.).v
Combining the 2016 figures from tables 1 – 4, the total GP clinical (HSE) income from the state
was €604,880,966 in 2016 which was boosted to €622,880,966 when non-HSE social welfare
payments were included. However, the TCD Report suggests a €29 million higher payment in

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2014 from this reports calculation of public GP payments which is reduced to a €11 million
difference if social welfare payments are included in GP income. (Table 5.)
Table 3. Non-Clinical/Non-HSE Public GP Payments
2016 2014
Department of Social Welfare (Est.) 18,000,000 18,000,000
GP Training (Est.) 20,000,000 20,000,000
Table 4. GP Co-operative Costings
2016 2014
Caredoc GP Co-operative 8,805,000 7,855,000
K Doc (GP Out of Hours Service) 1,825,000 1,876,000
MIDOC 892,000 853,000
Shannondoc Ltd (GP Out Of Hours Service) 4,795,000 4,786,000
South Doc GP Co-operative 8,343,000 8,247,000
Westdoc (GP Out Of Hours Service) 1,872,000 1,409,000
LukeDoc, DL Doc, EastDoc & DubDoc (Est.) 600,000 600,000
Total GP Cooperative Costs 26,532,000 25,026,000
The 2016 and 2014 payments figures calculated for public GP services calculated in this report
would be very similar to those provided by both the CSO and OECD in the HF.1.1 - Government
Financing Schemes column of the System of Health Accounts Table, HP.3.1 Medical Practices 6B:
Current Health Care Expenditure by Health Care Provider and Health Care Financing Scheme. The
DPER Report figure of €586 million spend on government financing schemes is exactly the same
as the SHA figure. The 2014 TCD Report figure of €543 million public spend is significantly
different to the SHA figure of €492 million for the same year. (Table 6.)
Table 5. Total Clinical and Non-Clinical Public GP Payments
2016 2014
Total GP Clinical (HSE) Income 604,880,966 514,176,899
Total GP State Income (Including Social Welfare) 622,880,966 532,176,899
DPER Report Government/compulsory schemes 586,000,000
DPER Report Government + Maternity 600,700,000
TCD Report 543,000,000

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Table 6. System of Health Accounts payments to Medical Practices (HP.3.1) 2013-2016
Combining the calculation of the total GMS spend per GMS patient with the GMS population
share of the total HSE spend gives the total HSE cost per GMS patient which includes payments
for non-GMS/Universal services such as ante-natal and post-natal care, primary immunisations
and cervical screening. The number of GMS patients covered by general practice is always under-
reflected and E111 patients activity is included in the costs calculation but never in the
population served calculation. (Table 7.)
The general practice attendance rates of a national population follow a J shaped distribution: A
very high year 1 attendance that rapidly decreases over the next few years and starts to slowly
but inexorably rise for the men in their 20s and earlier for women due to their contraception and
antenatal needs. However, the GMS population comprises the under 6 population, the older
population along with the poorer and sicker population resulting in a much higher demand for
general practice activity than the national population as a whole.
‘Table 2 GMS: Summary of Statistical Information for 2012 – 2016’ taken from the PCRS Annual
Report attributes an average payment to GPs per eligible person of €252.12 in 2016 and €235.06
in 2014.viii These figures per GMS patient are calculated by aggregating all the PCRS direct
payments to GPs for GMS and non-GMS services (ante-natal and post-natal care, cervical
screening, methadone payments, etc) and dividing the total by a weighted yearly average of
GMS patients. The inclusion of some payments for services provided to private patients in the
numerator but not increasing the nominator in the equation inflates the direct payments per
GMS payments in 2016 from €238 to €252. Not including patients who are still being served by
GPs but whose medical cards have been suspended due their inability to comply with the HSE
bureaucratic process and E111 patients further inflates the GP payment per medical card patient
figure.
If the total public spend on GMS patients are to include the GMS share and non-GMS share of
both the direct GP and indirect GP spend, the total payments per GMS patient (not including
dispensing fees of €1.2 million in 2016 and €1.4 million in 2014) were €257.90 in 2016 and
€235.19 in 2014 for an older, poorer and sicker demographic. Table 8
2013 2014 2015 2016
Medical Practices (HP.3.1) €million €million €million €million
All Current Health Care Expenditures - ICHA-HF Code (HF.1 - HF.3) 888 879 941 994
Govt Financing Schemes and Compulsory Contributory Health Care
Financing Schemes - ICHA-HF Code (HF.1)
520 492 549 586
Voluntary Health Care Payment Schemes - Voluntary Health
Insurance Schemes - ICHA-HF Code (HF.2.1)
57 66 57 57
Household Out-of-Pocket Payments - ICHA-HF Code (HF.3) 311 321 336 351

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Table 7. GMS: Summary of Statistical Information for 2013 – 2017 calculation of PCRS payments per
person
LineNo.
Adapted from Primary Care Reimbursement Service Statistical Analysis of Claims and Payments 2017
Year ended December:- 2017 2016 2015 2014 2013
1 Number of Eligible Persons in December 2,097,330 2,154,297 2,166,159 1,928,276 1,974,806
2 Total Payments 522,375 515,166 460,973 424,646 447,815
3 Avg. Payment to GPs per Eligible Person €249.07 €252.12 €226.07 €235.06 €243.08
4
5 PCRS Table 15 GMS: Payments to General Practitioners
6 - Benefits to retired DMOs + their dependants (a.) 2,618,366 3,000,931
7 - Former District Medical Officers (b.) 1,341,918 1,341,918
8 - TOTAL 524,993,302 518,166,985
9 TOTAL - (a.) 522,374,936 515,166,054
10 TOTAL - ((a.) + (b.)) 521,033,018 513,824,136
11 SUPERANNUATION FUND (c.) 29,374,034 29,343,755
12 TOTAL - ((a.) + (b.) + (c.)) 491,658,984 484,480,381
13
14 W Behan Calculations of payments/person
15 Avg. Payment to GPs per Eligible Person (Line 9/1) 249.07 239.13
16 Mid-Year Popult'n (2 adjacent end year counts/2) 2,125,814 2,160,228 2,047,218 1,951,541
17 Line 8/Mid-Year Population 246.96 239.87
19 Line 10/Mid-Year Population (GMS only €) 245.10 237.86
21 Line 28/Mid-Year Population (All GP €) 251.78
22 Line 31/Mid-Year Population 255.06
23
24 Total Payments and Reimbursements
25 Fees 394,800,000
26 Allowances 148,330,000
27 Investment in GP 780,000
28 Total (Included non-GMS income) 543,910,000
29
30 https://www.hse.ie/eng/services/publications/corporate/hse-annual-report-and-financial-statements-2017-pdf.pdf
31 Doctors’ Fees & Allowances (HSE Annual Report) 557,467,000 550,988,000
Number of eligible persons in 2017 includes the number of eligible persons with Medical Cards and GP Visit Cards.
Average payment to GPs is inclusive of GP Visit card costs and exclusive of superannuation paid to retired DMOs

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Table 8. This Reports Calculation of GMS + Non-GMS payments per GMS patient
2016 2014
Total HSE Spend on GMS Patients minus dispensing fees plus Non-GMS Income
GMS Payments to GPs minus Non-GP expenses 513,824,136€ 423,303,731€
Total GP Cooperative Costs 27,132,000 25,626,000
GMS Share OOH Cooperative Costs 66% 63%
17,871,942.89 16,026,295.93 2016 2014
GMS Share Non-GMS Costs
Irish Family Planning Association (IFPA) 377,700€ 372,000€ 0.3
Primary Childhood Immunisation Scheme 6,925,243€ 2,246,315€ 1 0.3
Health (Amendment) Act 1996 56,600€ 54,074€ 0.3
Heartwatch 294,596€ 305,940€ 0.3
National Cancer Screening Service 3,642,272€ 3,779,026€ 0.3
Methadone Treatment Scheme 6,183,222€ 5,858,122€ 0.8
GP Training 9,115,655€ 8,402,036€ 0.46 0.42
Total GMS Share Non-GMS Costs 44,467,231 37,043,809
Mid-Year GMS Population 2,160,228 1,951,541
Total HSE Costs for GMS Population 558,291,367 460,347,540
Dispensing Fees 1,167,766 1,360,353
Total HSE Costs minus Dispensing Fees for GMS Population 557,123,601 458,987,187
Total GMS Cost/GMS Population 237.86€ 216.91€
Total HSE Costs/GMS Population 258.44€ 235.89€
Total HSE Costs (minus Dispensing Fees)/GMS Population 257.90€ 235.19€
GMS Share Total Funding

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2. GP PRIVATE PAYMENTS
The majority of Irish GP private payments are an out of pocket expenditure, of which a maximum
of 10% is refunded by voluntary health insurance companies.ix For those who claim their
entitlements, tax relief on GP expenses is given at the standard rate of 20%. This tax relief
from the state is considered by DPER as an extra income for general practice, but GPs usually
pay tax at the marginal rate on this income, so half of this revenue expense is returned
directly to revenue from GP income tax payments. Health insurance companies might directly
pay some GPs for providing procedures such as orthopaedic injections, minor surgery and
cryotherapy, however that is a relatively minor sum. Non-clinical private income for GPs
would include completing insurance and legal reports. In Ireland occupational health is often
provided specialist clinics which often do not provide general practice services. However,
unlike most other countries, much of antenatal care and nearly all contraceptive services and
paediatric care is provided in general practice along with a lot of informal chronic disease
management. Some of these services would be accounted for in other countries under non-
GP costs in national health accounts.
The standard calculation for GP out of pocket income for clinical services should be based on
relevant, reliable and accessible data. The CSO does produce the out of pocket expenditure on
GP fees figure in its Household Budget Survey which is based on diary data exclusively. i.e.
the figure is based on the exact expenditure as recorded by households over a 2-week period.
 The CSO Household Budget Survey HS12 Average Weekly Household Expenditure figure
09.01.04 Doctor (not consultant) provides the national out of pocket spend per
household on GP fees of €2.08. (Table 9.)
Table 9. Household Budget Survey Data. HS012: Average Weekly Household
Expenditure (Euro) by Location, Expenditure type and Year
2015
State
09.01 Medical expenses/services and therapeutic equipment 18.48
09.01.01 Prescription medication 3.69
09.01.02 Over the counter (OTC) medicines 3.07
09.01.03 Other medical products (plasters, bandages, etc.) 0.27
09.01.04 Doctor (not consultant) 2.08
09.01.05 Dentist 1.62
09.01.06 Specialist practice (including consultant, orthodontist) 3.30
09.01.07 Physiotheraphy and other parmedicial services/fees 1.21
09.01.08 Services of medical analysis labs 0.33
09.01.09 Hospital services 1.83
 If this figure is extrapolated to 52 weeks of the year by the 2016 CSO census figure E1001
of 1,702,289 private households (2014 est. 1,678,249) it produces a 2016 national spend
of €184,119,578 and a 2014 spend of €181,519,412.

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 This figure can then be used as the reference to calculate the voluntary health insurance
10% refund of GP Fees based on TILDA data to give the total private spend on clinical
general practice.x
 This reports calculation of total GP private income including health insurance subsidies
but excluding private hospital consultants in the community, minor injuries clinics and
community intervention teams provides a figure of €203 million for 2016 and €200
million for 2014 for total GP private clinical income. These figures are much lower than
the DPER Report 2016 private spend figure of €351 million and TCD Report of a 2014
annual private spend of €315.5 million on general practice.
 System of Health Accounts data is derived from a combination of CSO (which would
include Household Budget Survey data), HSE data, Revenue data and interpretation of
the combination of these sources.
 The HS12 09.01.04 Doctor (not consultant) and 09.01.06 Specialist practice (including
consultant, orthodontist) out of pocket spend are used together to inform the System of
Health Accounts SHA06: Household Out-of-Pocket Payments for Ambulatory Health Care
Provider (HP.3) (Medical Practices - ICHA-HF Code HF.3.1) figure. (Table 10a) It is this
combination of GP and Consultant (but not orthodontists) out of pocket figure that is
used to provide the private spend on general practice figure in both the October 2018
Department of Public Expenditure and Reform Review of Government Expenditure on
General Practice and also the 2017 TCD document ‘A Future Together Building a Better
GP and Primary Care Service’ which was later presented to the Oireachtas Health
Committee.xi,xii,xiii
 The System of Health Accounts SHA06 Voluntary Health Care Payment Schemes -
Voluntary Health Insurance Schemes - ICHA-HF Code (HF.2.1) figure of €57 million (Table
10b) aggregates GP, Psychiatrist and Consultant health insurance payments to those
professions. It is this GP and Non-GP aggregate Health Insurance payment that is
identified in the DPER and TCD documents for calculation of total health insurance spend
on general practice. TILDA data suggests the health insurance spend on general practice
is closer to €18 million per year.

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Table 10a. Systems of Health Accounts Household Out-Of-Pocket Payments for Ambulatory
Healthcare Providers. SHA06: Current Health Care Expenditure (Euro Million) by Type of
Financing Scheme, Provider and Year
2013 2014 2015 2016
Household Out-of-Pocket Payments - ICHA-HF Code (HF.3)
Ambulatory Health Care Provider (HP.3) 1,052 1,069 1,072 1,079
Medical Practices (HP.3.1) 311 321 336 351
Dental Practices (HP.3.2) 464 470 465 473
Other Health Care Practitioners (HP.3.3) 180 180 173 155
Ambulatory Health Care Centres (HP.3.4) 33 38 36 35
Table 10b. SHA06 Health Care Payment Schemes for Medical Practices (HP.3.1)
2013 2014 2015 2016
Medical Practices (HP.3.1) €million €million €million €million
All Current Health Care Expenditures - ICHA-HF Code
(HF.1 - HF.3)
888 879 941 994
Govt Financing Schemes and Compulsory Contributory
Health Care Financing Schemes - ICHA-HF Code (HF.1)
520 492 549 586
Voluntary Health Care Payment Schemes - Voluntary
Health Insurance Schemes - ICHA-HF Code (HF.2.1)
57 66 57 57
Household Out-of-Pocket Payments - ICHA-HF Code
(HF.3)
311 321 336 351
This substantial error in the DPER report is that it utilises the SHA code HP.3.1 which is intended
to give a figure for all non-hospital medical practices and attributing that combined expense to
general practice. The OECD Classification of health care providers (ICHA-HP) clearly sub-divides
the SHA codes 3.1 for Medical Practices into 3 constituent parts and explains where each
medical discipline belongs Tables (10a and 10b.)
 HP.3.1.1 Offices of general medical practitioners
 HP.3.1.2 Offices of mental medical specialists
 HP.3.1.3 Offices of medical specialists (other than mental medical specialists)
The TCD report states “General practice in Ireland is a combination of medical practices,
ambulatory healthcare centres and providers of home health care services thus fulfilling three
out of the five OECD categories”. These categories would be (SHA HP.3.1 which is a combination
of HP.3.1.1, HP.3.1.2 and HP.3.1.3) ambulatory healthcare centres (HP.3.4 which is potentially a
combination of HP.3.4.1, HP.3.4.2, HP.3.4.3 and HP.3.4.9) and providers of home health care
services (HP.3.5). This is assuming a rather broad interpretation of what constitutes Irish general
practice. It apparently including services such as the public and private minor injuries clinics
(which would be categorised in the UK as ‘Type 3 Departments - Other A&E/Minor Injury Unit’
and would not appear in general practice funding statistics). It also includes corporate provided
home health services such as administering i.v. antibiotics which are specifically not funded
under the GMS contract and delivered independently of GMS GPs.
The TCD report uses a similar figure to the DPER report for its 2014 private GP spend. This
apparently aggregates elements of HP.3.1.1 and HP.3.4 and HP.3.5 data to derive a figure a total
annual GP spend. However, the figure of €315.5 million in the TCD report for private GP spend is
the same as the average of the 2013 and 2014 SHA 3.1 out-of-pocket medical expenditure
figures, which is €116 million more than the calculation in this report

16 | P a g e
3. TOTAL GP PAYMENTS
Points 1. and 2. deliver a total spend on Irish general practice.
The DPER report has a figure of €994 million total spend on Irish general practice in 2016 which
includes public direct and indirect spend, private OOP spend and social welfare income. This
inflates the total GP spend by €167 million compared to the calculation in this report, or €187
million if Social Welfare income is not included in the calculation. The DPER implies 5% of the
total current (not capital) health budget is spent on Irish general practice.
The TCD report authored by Professor Emeritus Tom O’Dowd and colleagues ‘A Future Together
Building a Better GP and Primary Care Service’ (TCD Report) refers to a 2014 calculation of 4.5%
total spend on Irish general practice as a proportion of the total health spend. The TCD Report
calculate the total 2014 GP spend to be €858.6 million when this report calculates the total
public and private GP 2014 spend to be €713.8 million, or €733.8 million if Social Welfare income
is included.
Both the DPER and TCD reports figures over reflect the GP spend as a proportion of the total
health spend on general practice by
o Inflating the GP private out of pocket spend
o Not highlighting that the included GP superannuation spend is a real time spend
when the public service pensions are on a ‘pay as you go’ basis with a significant
proportion of the pension liability of current HSE staff deferred to a future date
after they have retired. This has the effect of reducing the HSE current health
spend on staff.
o Only using the health current spend figure and not including the capital spend
when general practice has no direct access to this capital fund.
The inflation of the total GP spend in the DPER Report results in a total spend approaching 5% of
the total health budget. A closer analysis of all the available data results in a GP spend of
approximately 4% of the total current health budget. This figure is reduced to 3.8% if the total
capital spend is included in the calculation. The total health spend on general practice is even
lower if future public service pension costs are included (GPs have defined contribution and
public servants have defined benefit pensions). The TCD Report figure of 4.5% total health spend
on Irish general practice is similarly biased upwards by about 20% from a 2014 figure of 3.7%
total health spend on general practice. (Table 11.)

17 | P a g e
Table 11. Total GP Payments in the 3 Reports Aggregated and Presented as a Percentage of the
Total Current/Current + Capital Health Budget
It is clear that the classification of what constitutes general practice and therefor what payments
are included in the analysis is one of the significant discrepancies between this reports analysis
and the DPER and TCD reports. The TCD report states “General practice in Ireland is a
combination of medical practices, ambulatory healthcare centres and providers of home health
care services thus fulfilling three out of the five OECD categories.”
Table 12a illustrates the OECD definitions of physicians, all of which appear to be included in the
GP payments data reported by DPER. Table 12b. breaks down the taxonomy of the OECD
ambulatory health care providers (ICHA-HP) and compares it to the SHA healthcare provider
classification 3.1 which doesn’t subdivide the ambulatory healthcare providers as the OECD
analysis does. The usage of the SHA healthcare provider classification rather than the more
Total Clinical and Non-Clinical Public and Private GP Payments
2016 2014
PUBLIC PAYMENTS
Total GP Clinical (HSE) Income 604,880,966 514,176,899
Total GP State Income (Including Social Welfare) 622,880,966 532,176,899
DPER Report Government/compulsory schemes 586,000,000
DPER Report Government + Maternity 600,700,000
PRIVATE PAYMENTS
This reports analysis Out-of-pocket payments 184,119,578 181,519,412
This reports Health Insurance Co-payments 18,411,958 18,151,941
This reports total Private Payments 202,531,536 199,671,353
DPER Report Out-of-pocket payments 351,000,000
DPER Report Health Insurance Co-payments 57,000,000
TOTAL CLINICAL PUBLIC AND PRIVATE GP PAYMENTS
This report 807,412,502 713,848,252
DPER Report 994,000,000
TOTAL PUBLIC AND PRIVATE NATIONAL HEALTH EXPENDITURE
Current 20,332,179,000 18,843,688,000
Capital 1,169,492,000 898,515,000
Current + Capital 21,501,671,000 19,742,203,000
GP BUDGET AS A % OF THE CURRENT HEALTH EXPENDITURE
This report 4.0% 3.8%
DPER Report 4.9%
TCD Report 4.6%
GP BUDGET AS A % OF CURRENT + CAPITAL HEALTH EXPENDITURE
This report 3.8% 3.6%
DPER Report 4.6%
TCD Report 4.3%

18 | P a g e
detailed OECD classification of healthcare providers is resulting in the inclusion of non-GP private
income which significantly inflates the GP figures. (Table 13.)
Table 12a. OECD Discription of Ambulatory Health Care Providers (ICHA-HP) HP.3.1.1-3
(Doctors)
HP.3.1.1
Offices of
general
medical
practitioners
This includes general/family practitioners in private offices; physician walk-in
offices/centres; paediatricians providing general medicine in private offices;
district medical doctors; family medical practitioners; medical doctors
(general) and primary health care physicians
HP.3.1.2
Offices of
mental
medical
specialists
Including practices of independent psychiatrists; mental health paediatricians
and medical doctors practicing as psychoanalysts
HP.3.1.3
Offices of
medical
specialists
(other than
mental
medical
specialists)
This item comprises establishments of health practitioners holding a degree of
medical doctor with a specialisation other than general medicine or mental
health (equivalent to ISCO-08 Code 2212) and includes offices of surgeons,
aesthetic surgeons, anaesthetists, cardiologists, dermatologists, emergency
medicine specialists, gynaecologists, endocrinologists, ENT (ear, nose, throat),
gastroenterologists, infection specialists, nephrologists, obstetricians,
ophthalmologists, orthopaedists, pathologists, paediatricians for specialised
care (e.g. oncological treatment), pathologists, preventive medicine
specialists, radiologists and radiotherapists, rheumatologists, specialist
physicians (internal medicine), urologists

19 | P a g e
Table 12b. OECD and SHA Taxonomic Hierarchy of Ambulatory Health Care Providers (ICHA-HP)
Code Description SHA 1.0 codes
HP.3 Providers of ambulatory health care HP.3
HP.3.1 Medical Practices HP.3.1
HP.3.1.1 Offices of general medical practitioners HP.3.1
HP.3.1.2 Offices of mental medical specialists HP.3.1
HP.3.1.3 Offices of medical specialists (other HP.3.1
than mental medical specialists)
HP.3.2 Dental Practice HP.3.2
HP.3.3 Other health care practitioners HP.3.3
HP.3.4 Ambulatory health care centres HP.3.4
HP.3.4.1 Family planning centres HP.3.4.1
HP.3.4.2 Ambulatory mental health and HP.3.4.2
substance abuse centres
HP.3.4.3 Free-standing ambulatory surgery centres HP.3.4.3
HP.3.4.4 Dialysis care centres HP.3.4.4
HP.3.4.9 All other ambulatory services HP.3.4.5,
HP.3.4.9
HP.3.5 Providers of home health care services HP.3.6
Table 13. Comparison of Household Budget Survey and System of Health Accounts of General
Practice Out of Pocket and Health Insurance Income
2016
Out of pocket
spend
Health Insurance GP
Payments
Total Private Clinical
Spend
Household Budget Survey 184,119,578 18,411,958 202,531,536
Systems of Health Accounts 351,000,000 57,000,000 408,000,000
2014
Out of pocket
spend
Health Insurance GP
Payments
Total Private Clinical
Spend
Household Budget Survey 181,519,412 18,151,941 199,671,353
Systems of Health Accounts 321,000,000 55,000,000 336,000,000

20 | P a g e
4. COMPARISON OF THE ANNUAL PAYMENTS PER PATIENT:
IRISH GMS/ALL PATIENTS vs. UK NHS PATIENTS
The DPER Report stated that “In 2016, the average cost per registered patient was €252, a level
that has roughly held since 2011. By comparison, in euro terms NHS England expenditure on GPs
in 2016 (£151.37) was in the range €168 to €216 per registered patient (at exchange rates €1 =
STG £0.7 and €1 = STG £0.9).”
 Irish patients covered are the youngest, oldest, poorest and sickest 43% of the national
population which are all features associated with a higher attendance rate and the
comparison is the full UK population. The 57% of the Irish population who are private
patients and less frequent attenders are not included in this calculation. The UK
population density is 3.5 times the Irish resulting in some economies particularly affecting
out of hours care.
 The NHS population used for the denominator in the calculation appears to be
significantly more that the total National population. The Irish GMS population in reality
is larger than the official GMS population used to provide the denominator when
calculating GP income per patient. Many Irish GMS patients have their medical card
capitation payments to their GP stopped on bureaucratic grounds and also GPs covering
European E111 patients is not included. The UK NHS population is a lot larger than the
national population survey figure because the NHS population includes UK citizens living
or travelling abroad are missed in the national census. However, the UK national census
does not count non-national citizens who are residing in the UK less than 12 months but
might still attend the GP services which would part mitigate this discrepancy. OECD
calculation of UK GP workloads uses the lower UK population rather than the higher NHS
patient numbers as reference figures in the GHS data.
 Irish public patients generally have nearly all their GP costs borne by the state but 9% of
UK patients primary care costs are out-of-pocket according to the 30th Edition of the
LaingBuisson UK Healthcare Market Review.
 Irish GPs often provide services for free to patients who historically have had a medical
card but it was withdrawn before its due renewal date on the basis of an administrative
exercise of “medical card probity”, thus reducing the payments (numerator) in reality but
only artificially reducing the denominator in the Irish GP payment per patient calculation.
 The calculation of Irish GMS funding in this report includes indirect and direct out of
hours as well as all direct IT and capital funding. The 2016 Average Payment to GPs per
Eligible Person is produced by dividing Total GMS Payments for GMS Services + Non-GMS
Services for 24-hour care including capital funding by the weighted (c. average) Year
Population to produce the figure of €257.90. The equivalent payment per patient in 2014
was €235.19. The non-GMS services include payments for universal antenatal care,
primary immunisation and cervical screening. When the Total GMS Payments for GMS
Services were divided by the mid-year population it produces a sum of €237.86 for 2016
and €216.91 in 2014. (Table 8.)
 If the figures in this report were used to determine a total national Irish payment per head of
population it would provide a 2016 figure of €170.35 (DPER 2016 calculation of €209.72) and a

21 | P a g e
2014 payment figure of €153.67 per head of national population (TCD 2014 calculation €184.81)
which are much lower than the official NHS funding figure is once Purchasing Power Parity is
taken into account.
Table 14b. OECD Stat Government Expenditure on Medical Practices 2011-2016 Ireland and UK
Dataset: Health expenditure and
financing
Financing
scheme
Government/
compulsory
schemes
Function Current expenditure on health (all functions)
Provider Medical practices
Measure Current prices
Year 2011 2012 2013 2014 2015 2016
Country Unit
Ireland Euro, Millions 551.9 577.6 520.0 491.8 548.7 585.7
United
Kingdom
£Stg Millions 11,424.4 11,649.9 12,229.8 12,895.6
Data extracted on 01 Dec 2018 19:25 UTC (GMT) from OECD.Stat
The English figure of £151.37 GP payment per patient comes from the Total NHS Payments To
General Practice 2016/17 Report which refers to £8,883,780,328 being paid to English General
Practice and uses a registered English patients figure of 58,688,866.xiv This financial sum is more
than the equivalent GP Earnings and Expenses Estimates Report figure of £8,072,505,000 as it
also includes some indirect payments to general practice for the provision of the same service
which would be also be included in Ireland. However
Table 14a. Comparison of Irish & UK GP Payments per Head of National Population Depending on Data
Source
Total Direct and Indirect GP Payments per Head of National
Population for Clinical Activity
OECD Current
Government
Expenditure on
Medical Practices/
Population
Year
Irish
Population
Irish Data (€)
NHS Payments to General Practice
England
(1,000s)
This
Report
DPER
Report
TCD
Report
Official
figurea
Payment/
Populationa
Payment/
Populationb Ireland (€) UK (£)
2014 4,645.40 153.67 184.81 105.86
2016 4,739.60 170.35 209.72 £151.37 £160.74 £169.90 123.58 196.43
a. Total English payment figure comes from https://digital.nhs.uk/data-and-information/publications/statistical/nhs-
payments-to-general-practice/nhs-payments-to-general-practice-england-2016-17
b. Total English payment figure (excluding drugs) comes from the average of 2015-2017 payments
https://digital.nhs.uk/data-and-information/publications/statistical/investment-in-general-practice/investment-in-
general-practice-2012-13-to-2016-17-england-wales-northern-ireland-and-scotland

22 | P a g e
 It is less than the English Investment in General Practice 2016/17 (excluding
reimbursement of drugs) figure of £9,579,322,000 (The average 2015/16 and 2016/17 is
£9,314,726,000) which would include indirect payments to general practice and inflate
the average payment accordingly.
 The UK Office for National Statistics produces an end 2016 population figure of
55,443,750 which is significantly less than the 58,689,304-figure used to calculate the UK
GP payment of £151.37 per patient.
 If the 2016/17 English Investment in General Practice sum was divided by the ONS
population calculation, if delivers a GP payment per patient of £172.77 (€191.96 -
€246.81).
 The 2016 UK SHA total current expenditure in UK medical practices figure of £14,528
million is a calculation provided by the ONS (Government spend of £12,896 million on
NHS and a £1,632 million out-of-pocket spend on general practice which is derived from
the 30th Edition of the LaingBuisson UK Healthcare Market Review). These are the same
SHA categories used in the DPER and TCD reports to provide a figure for total Irish
general practice funding. When the SHA total current expenditure on UK medical
practices is divided by the UK 2016 population of 65,648,054 it results in a GP payment
per patient of £221.30 (€245.89-€316.86).
 It would be more realistic to combine the average of the 2015/16 and 2016/17
Investment in UK General Practice (Excluding Reimbursement of Drugs) Cash figure of
£10,916 million with the LaingBuisson 9% out-of-pocket spent (potentially missing the
corporate spend on general practice in London) to give a total UK General Practice
(Excluding Reimbursement of Drugs) spend figure of £11,996 billion for the 2016 calendar
year. That is £182.72 spend per patient (€203.03 - €261.03)
 The Irish €252.12 per GMS patient government spend figure spend or if the total non-
GMS general practice spend (which covers private patients) is included in the calculation:
with no recognition that some of this figure funds a population not included in the
calculation.
 When the 2016 UK population and GP funding equivalently produced data are compared
to the Irish data, these figures are much closer to the Irish figure of €237.86 GMS spend
per GMS patient.

23 | P a g e
5. THE DIFFERENCE BETWEEN UK AND IRISH PRACTICE NURSE WORKLOAD
Is based on the 2018 Connolly et al Economic and Social Review analysis of Irish and UK
nurse workload. This seems to misinterpret good QResearch data and correctly interpret
very limited Northern Ireland data. Both analyses have the effect of exaggerating UK
nurse workload when referring to a lesser use of practice nurses in Ireland compared to
other countries.xv, xvi
The QResearch nurse activity figure of 34% of all clinical visits comes from the total sum,
of Health Professional Group 2 activity which includes community nurses, palliative care
nurses and health visitors’ visits. Therefor practice nurse activity would cover far less that
34% of the total clinical visits stated in the QResearch data.
Connolly et al state that the average number of practice nurse visits among the CHD
patients was 1.6 in the Republic of Ireland and 2.1 in Northern Ireland (Cupples et al.,
2008), with Republic of Ireland nurses covering 22% of all GP visits and Northern Ireland
practice nurses seeing 32% of the patients based on activity serving one disease group.
Subsequent Healthy Ireland data suggests Irish practice nurses performed 27% of all
clinical consultations in 2015 (GP 4.3, GP nurse 1.6 visits p.a.) and 24% of all visits in 2016
(GP 4.5, GP nurse 1.4 visits). The 2015 Health Interview Survey suggests that practice
nurses covered 32% of all GP visits in 2015 (6.2 GP, 3.1 GP nurse visits), which is a higher
proportion of the clinical activity compared to the more extensive report ‘Estimating the
Volume & Growth in Consultation Rates in General Practice in Northern Ireland, 2003/04
to 2013/14: Analysis of Survey Returns from General Practices’. This Northern Ireland
report estimation of consultation rates was based on 35 practices (204,053 patients) in
2003/04 and 42 practices (249,893 patients) in 2013/14. These practices had a combined
list size of 254,213 in 2004 and 269,486 in 2014, and therefore provide a more reliable
comparison for UK data than the Cupples et al paper. In fact, the comparison of the
extended trends of GP Nurse workloads as a proportion of the overall clinical workload as
provided in the most reliable Northern Ireland 2004 to 2014 data with the most reliable
2015 to 2018 Irish data displays very similar outcomes from both jurisdictions. (Table 15,
Chart 1.)

24 | P a g e
Table 15a. The Difference Between Irish and UK GP Practice Nurse Workload as a % of Total Clinical Visits
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
VisitRates
N.I. GP Surgery
& Home Visits 3.1 3.3 3.7 3.7 3.8 4 4.3 4.5 4.6 4.8 5
N.I. GP Nurse
Visits 1.1 1.4 1.5 1.6 1.5 1.8 1.9 2 2 1.9 1.8
Healthy Ireland
GP Visits 4.3 4.5 3.8
Healthy Ireland
GP Nurse Visits 1.6 1.4 1.4
CSO H.I.S. GP
Visits 6.2
CSO H.I.S. GP
Nurse Visits 2.9
Nursevisitsas%
oftotalClinical
Visits
Northern
Ireland
25% 29% 29% 30% 29% 31% 31% 31% 30% 28% 26%
Healthy Ireland 27% 24% 27%
Health
Interview
Survey
32%
Chart 1. Trends in Irish and Northern Irish GP Nurse Clinical Visits as a Percentage of the Total
Clinical Visits
0%
5%
10%
15%
20%
25%
30%
35%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Trends in Irish and N.I. GP Nurse Visits as % of Total Clinical Visits
Northern Ireland Healthy Ireland
Health Interview Survey Linear (Northern Ireland)
Linear (Healthy Ireland) Linear (Health Interview Survey)

25 | P a g e
6. DOES NURSE TRIAGE IN GENERAL PRACTICE RESULT IN SAVINGS FOR THE
OVERALL CYCLE OF CARE?
The extrapolated savings benefits from utilising nurse triage in a single 2007 paper by
Lordonxvii is subject to many caveats. Nor have its results been reproduced by Cochrane
systematic review or more recent research. The “efficiency value” for an OOH co-op
seems to be assessed in terms of lower payroll costs and decreased time between co-op
contact and clinical consultation, with the assumption that all care is homogenous. There
is no regard for clinical outcomes, the next day activity as a result of a nurse dealing with
an out of hours contact compared to a GP dealing with the same contact, or the full cycle
of care. A 2005 systematic review of the effect of telephone triage on overall health
service use found no clear benefits.xviii The more recent ESTEEM Trial has shown that
telephone triage is not associated with a reduction in overall clinician contact time during
the index day. Also, Nurse triage was associated with an increased follow-up attendance
rate compared to GP triagexix, xx.

26 | P a g e
7. PROOF OF THE EFFICIENCY OF IRISH GENERAL PRACTICE
The lack of proof of efficiency of Irish general practice is an exposure of the poorly
informed nature of the health economics community narrative on this topic rather than a
review of the available evidence. Claiming inefficiencies in prescribing are solely a fault of
GPs when nearly all GPs have been paperless for well over a decade yet they we still do
not have national e-prescribing reflects very poorly on national GP management. This
would by default develop a national database of individual GP prescribing habits in
conjunction with their patient demographics. Then GPs could easily and anonymously be
compared which would provide a further nudge to towards more rational prescribing.
Regarding the international evidence;
 Barbara Starfields 2012 Sespas report found that adding one more one primary
care physician per 10,000 population reduces death rates from 2% to 6%,
particularly reducing health inequality, inpatient admissions by 6%, outpatient
visits by 5%, emergency room visits by 10% and surgeries by over 7%xxi.
 A 2014 BMJ systematic review of 48 papers found that continuity of care with a
GP is associated with reduced emergency department attendance and emergency
hospital admissions.xxii
 A study published in Health Affairs of 1,045 US primary care practices found that
small primary care practices had a lower rate of preventable hospital admissions,
particularly if they were physician as opposed to hospital owned practices. This
was despite larger practices scoring better on the bureaucracy of care.xxiii
 A more recent Annals of Family Medicine paper comparing work practices that
are associated with high as opposed to average value primary care delivery
found the higher value practices were associated with a much lower spend on
inpatient surgical services, outpatient hospital visits and prescription
medications. These higher value practices were smaller, offered less formal
“quality measures” as well as spent less on their overhead space and
equipment compared to the average quality practices but provided more risk-
stratified care management and coordinated care.xxiv
 All this work indicating smaller practices can have better outcomes compared
to larger organisations was recently supported by UK research that found that
improved clinical outcomes and economies of scale do not automatically result
from ‘scaling-up’ general practice.xxv
Considering the evidence measuring the value Irish general practice brings to the national
health system or the unique attributes of Irish general practice that are associated with
value, the 2017 DPER report did not consider;
 The 2/3rd Emergency Department attendance rate per capita in Ireland compared
to English ED activity as a surrogate measure of good Irish GP performance.xxvi, xxvii,
xxviii.
 Oddly, while the DPER report referred to 2006 research comparing 20 ROI and NI
practices to postulate that there was an under-utilisation of GP nurses in the ROI,

27 | P a g e
the DPER report did not review another paper that was produced by the same
research highlighting the better quality of service provided in the ROI. GP access
and particularly continuity of care was much better in the ROI, with 92% of ROI
patient able to see their own GP of choice within 2 working days when only 45%
NI patients could see their GP of choice within the same time period.xxix The
greater continuity of care provided by self-employed GPs in Ireland compared to
the UK has been shown to be associated with reduced unnecessary hospital
admissions.
 Irish GP continuity of care was previously assessed in the older population in 2001
and 2004. HESSOP II (2004) reported that participants typically reported having a
long association with their own GP; 40% were with their GP for more than twenty
years. A further quarter of the sample were with their GPs for between ten and
nineteen years.xxx
 The authors the DPER Report misinterpret UK and Australian data on the
proportion of time spent by GPs on non-clinical activities when comparing the
statistics to Irish data. A 2004 retrospective survey of Scottish GPs is used to
review the percentage of time spent on non-clinical activities and it is compared
to 2015 Irish retrospective survey data.xxxi They would have been better served
referencing the more reliable UK National GP Worklife Survey that was first run in
1998 with the 9th survey run in 2017. This indicated that in 2017, 61% of a GPs’
time was devoted to direct patient care, which was approximately the same as
the figures reported from 2015 but there is a slight trend downwards in the
proportion of time spent in direct clinical activity since 2005.xxxii This is very similar
to the Irish data. Noting the Australian GPs complaining about the “red tape” does
not appreciate the practice in Australian general practice of having to telephone
for authorisation before prescribing many drugs, which is not a system that is
practiced in the UK or Ireland.

28 | P a g e
CONCLUSION
It is important that the evidence supporting national health policy should not only be
convincing, but that it also should be reliable.
Both the TCD review of 2014 GP funding and the DPER review of 2016 data clearly
overstate the funding of Irish general practice by 20% and 23% respectively by predominantly
including non-GP income in their calculations. If the capital spend is also included, the total GP
funding as a proportion of the total healthcare spend is 3.6% for 2014 and 3.8% for 2018. These
percentages are much lower than the 4.5% and 5% quoted in the respective reports.
If the figures in this report were used to determine a total national Irish payment per
head of population it would provide a 2016 figure of €170.35 (DPER 2016 calculation of €209.72)
and a 2014 payment figure of €153.67 per head of national population (TCD 2014 calculation
€184.81) which compares very favourably to the total UK 2016 equivalent public and private
payment for GP services per head of national population of £182.72 spend per patient (€203.03 -
€261.03). This UK figure is derived from the 2016 Investment in UK General Practice (Excluding
Reimbursement of Drugs) Cash figure of £10,916 million with the LaingBuisson 9% out-of-pocket
spent (potentially missing the corporate spend on general practice in London) to give a total UK
General Practice spend figure of £11,996 billion for the 2016 calendar year.
The suggestion that GP nurses could be incorporated more into Irish general practice to
create more efficiencies is based on the DPER Report using a single relatively small study
reviewing a particular population. It fails to compare more reliable and extensive NI data with
recent equivalent Irish CSO HIS and Healthy Ireland data which shows similar GP nurse workloads
in both jurisdictions as a proportion of all clinical consultations in general practice.
The reputed savings from using more nurse triage requires ‘Walter Mitty’ analysis. It does
not attempt to consider the balanced international evidence on this subject and the extra-
workload resulting from nurse as opposed to GP initial contact.
Finally, the DPER report suggests a lack of proof of the efficiency of Irish General Practice.
This conclusion requires a poor awareness of the international research identifying the features
of general practice that enhance value in healthcare compared to alternative models of
healthcare provision. The low Irish ED attendance rate per capita compared to the UK, which can
be considered a proxy measurement of the efficiency of general practice has been missed in this
and other analyses. Also, the multiple studies identifying the ease of access and excellent
continuity of GP care that exists in Irish general practice compared to NI which is associated with
enhanced outcomes have also been left out of the DPER analysis.
This report makes no attempt to review the common narrative on GP clinical activity
rates or GP private fees which has been extensively addressed by the author and published on
https://www.slideshare.net/DrWilliamBehan/presentations

29 | P a g e
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