A general practitioner’s perspective on the guest blog by Dr Kevin Denny

Dr William Behan, co-author of “Does Eliminating Fees at Point of Access Affect Irish General Practice Attendance Rates in the Under 6 Years Old Population? A Cross Sectional Study at Six General Practices”

You can download a .pdf of this blog post with references here. 

Most of the state sponsored; CSO or university department generated statistics on general practice utilisation since 2001 have been based on surveys employing 1 year recollection. Dr. Denny uses Growing Up in Ireland (GUI) the largest database available for the purpose of determining the marginal effect of granting private under 6s patients medical cards. Intuitively this makes sense……or does it when the potential biases of that particular survey data are explored?

We really have to examine biases in statistics collection to determine what is more likely.

First of all, the Growing Up in Ireland (GUI) data is based on a questionnaire employing  9 month or 1 year recollection : The relevant question is: “Since <baby> was born, how many times have you seen, or talked on the telephone with any of the following about <baby’s> physical health

A general practitioner (GP), or family physician

A public health nurse or practice nurse ”[ii]

Review of the national and international data on surveys of this type suggests that this question automatically provokes a 30-40% degradation of recollection due to the time period of recall demanded in the survey (with the GMS patients’ disproportionately under-recollecting attendances).

Its raw data is subject to 3 other significant universally recognised biases:

1. proxy recollection which has the effect of further reducing recollection by 20%.

2. practice nurse consultations are recorded as public health nurse consultations, therefor under reflecting general practice attendance rates.

3. the salience (registered importance in the memory of the survey respondent) of the clinical consultation which appears to be less important for public patients due to a possible combination of the lack of fee associated with the consultation and the increased likelihood it will be perceived by the patient themselves as trivial compared to a private patients perception of their own consultations

There are two government figures on the suggested increase in attendance rate by new medical card patients; 0.4 and 0.9 per annum. I have not seen the method of calculating the 0.4 figure but I have seen the paper supporting the 0.9 figure. It is from GUI data which is subject to all the above biases and it miscalculated the number of new GMS patients by 60,000 (affecting the numerator) and has 2,800 more GPs in the denominator, which is larger than the government figure of 2,415.

The IMJ 2014 paper suggests an extra number of consultations of 750,000 brought on by introducing free GP access to the whole population.

Considering that

  • it is an audit and is not subject to many of the biases the GUI survey suffers from,
  • most of the biases affecting it are downward rather than upward with the exception of the relative difference in private/GMS attendance rates,
  • the extra demands of routine care in the new contract which will have a greater effect on current private than GMS patients,
  • the UK data which indicates attendance rates in this age group are over twice what GUI predicts for Ireland with minimal differences between the income groups and
  • NUI Galway data looking at the under 5 year old age group from the 2006 Lifeways study[iii] which has figures of overall GMS attendance rates that are remarkably similar to the IMJ 2014 data (but also has higher private attendance rates that cannot clearly be explained),
  • the population studied in the 2014 IMJ paper was the same as the 2013 IMJ paper by the same authors and it predicted previous and subsequent Northern Ireland GP visiting rates with remarkable accuracy

it appears that the IMJ 2014 paper should be the one used for considering future workload as its figures are taken from real world data and not fancy mathematical analysis of heavily biased data.

It is important that the data used to promote national health policy changes is not only convincing, but it must also be reliable. It appears that both the GUI data and the government sponsored analysis of it is not reliable enough to have any role in the debate about future health policy changes.

Where do these figures come from that suggest such a large degradation of recollection versus audit of GP records?

The OECD annual publication Health as a Glance states “estimates from administrative sources tend to be higher than those from surveys because of problems with recall and non-response rates”. The 2005 edition of OECD Health at a Glance reviewed GP consultation rates in 27 OECD countries. For 8 of the countries it had both administrative and survey data. Consultation rates measured by assessment of records were found to be 28% higher than rates assessed by survey (6.63 vs 5.17). [iv]

Eurostat, the European statistical office and the WHO clearly highlight the 1960s and 1970s work of Charles F Cannell and colleagues which identifies the degradation of recollection that occurs with time and the importance of salience of the questions in surveys.[v]

“45. There are three problems that health accountants must consider when contemplating the use of household surveys as the primary data source for estimating household expenditures:

i.               sampling error in surveys;

ii.              biases arising from non-sampling errors; and

iii.            lack of annual repetition of most household surveys.

Of these, the second is typically under-appreciated, and is behind the most important errors that can

arise when estimating household spending.”

“51. These non-sampling biases can be large (see Box 1), and tend to show the following patterns:

(i) The number of events forgotten increases proportionately with the length of the recall period.

(ii) Events with less salience or impact on the individual are more likely to be forgotten.

(iii) Proxy respondents tend to report 20% fewer events.”[vi]

There are other international papers that suggest that there is minimal degradation of recollection with time with the exception of the elderly and frequent attenders. However, on close examination of these there is often a significant difference between how the survey question is asked: survey questions that are longer and more detailed are more likely to provoke a reliable response than shorter survey questions such as used in GUI. Other papers don’t correlate patient recollection with general practice records, but compare recollection with proxy records such as state insurance payment records which will be missing telephone consultation activity, consultations in which a charge is not applied or when the receipt from the general practitioner is lost by the patient. Some surveys correlate issues other than general practice utilisation, or only correlate routine general practice utilisation with records and do not include acute episodic care.

But, the detractors from this concept of memory loss with time will all state, where is the recent evidence supporting this unreliability of survey data depending on the period of recollection rather than using Charles Cannell figures? We actually do not need to go very far to find it but we just need to travel back to 2001 when Ireland produced two surveys on GP attendance rates.

The 2001 CSO National Quarterly Household Survey was performed on a population of 44,844 and used a 2 week recollection period for GP consultations.[vii]  Living in Ireland Survey (LIIS) formed the Irish component of the European Community Household Panel (ECHP): an EU-wide project, co-ordinated by Eurostat, the statistical office of the European Union.  The final LIIS was performed also in 2001 on a population of 6,521 adults and employed a 1 year recollection of GP consultations. The recollection figures for GP utilisation rates were36% lower in the LIIS 1 year recollection than the CSO 2 weeks recollection, with public patients forgetting significantly more than private patients.

 

All  Patients GMS Only Private Only
LIIS 2001 3.2 5.3 2.2
CSO 2001 5 8.87 3.04
Reduced Recollection % 36% 40% 28%

 

(These are 2 separate samples reflective of the national population)

The question asked by LIIS 2001 was “During the last 12 months, about how many times have you consulted with each of the following either here in your own home or in their surgery or offices? Please include only consultations made on your own behalf and exclude those made on behalf of children or other persons …

Your family doctor, GP (including home visits by the doctor)“[viii]

The CSO 2001 question was DOCTOR: Did you consult with your GP or family doctor in the last 2 weeks?                                1.              Yes                                              2.              No”[ix]

(Note that this provides potential for under-recording attendance as multiple consultations in the last 2 weeks will only be reflected as one.)

 

So we have an Irish survey asking similar questions about GP utilisation but employing different recollection periods which seems to be the most plausible reason for the significantly different responses.

Come forward to 2006 and see what international best practice was in healthcare surveys. The European Health Interview Survey (EHIS) was developed between 2003 and 2006, and the first wave of it was implemented during the period 2006-2009 under a gentlemen’s agreement by 19 different countries.It requested reports of consultations with GPs during the previous 4 weeks.[x]

Irish results from the 2007 CSO National Quarterly Household Survey were not included in the EHIS wave 1 report due to the information collected not being comparable, particularly due to the different recall period. [xi]

Official Irish Adult GP attendance rate figures are based on the 2007 (sample population 21,253)[xii] and 2010(population 15,673)[xiii] CSO National Quarterly Household Surveys. They employed the same 1 year recollection of consultations as the 2001 Living In Ireland Survey. (Sample size 6,521)

The 2007 and 2010 CSO surveys show a much lower GP attendance rate for both GMS and private patients compared to the larger 2001 CSO survey (44,844 population) which was based on 2 weeks recollection, but almost identical consultation rates to the 2001 LIIS which was also based on a 1 year recollection. The 2007 and 2010 CSO surveys highlighted a reduced GP attendance rate for GMS patients as they get progressively older over the age of 54 y.o in 2007 and over the age of 64 y.o. in 2010 which is at odds with previous research. The 2007 CSO methodology was changed between the original pilot survey in early 2007 which demanded 2 week recollection to a 1 year recollection despite the common practice of the European Statistics Office.[xiv] The 2007 survey showed GMS patients attendance rates peaking in the 45-54 y.o. age group then tapering off with progressive age, and yet it did not generate a review of its methodology. These CSO surveys predict a much lower current number than the figure of approximately 24 million consultations occur in general practice annually (15.4 million GMS consultations and 8.8 million private consultations) predicted in the 2013 paper I co-authored.[xv] That was based on a population of 20,706 adults from 6 different general practices spread though out the country reflecting the national urban/rural device and national deprivation mix. They used the same practice management software the same way so their data could be considered comparable. That cohort was more reflective of the national age/sex/GMS demographics than both the 2007 and 2010 CSO surveys.

Extrapolating our findings to a national population of 4.59 million (2013 CSO), suggested that were private patients to attend at the same rate as GPVC patients, then one might anticipate an increase in general practice workload of 4.4 million consultations per year, which is well in excess of the figures currently used in planning of Universal Primary Care.[xvi] We suggested Irish GPs would need to provide 28 million consultations of work practices remained the same and there was universal free GP access. Extrapolation of RCGPNI Presidents 2015 figure for GP attendances in Northern Ireland to the Republic population suggests an expected attendance rate of 31 million consultations.

A report to North South Inter-Parliamentary Association in September 2013 States: “At least 350 GP practices are in operation in Northern Ireland.The average number of patients per practice is 5,374, (around 1,631 patients per GP). Patients consult their practice on average 6.5 times per year.This rate is 100% higher – (twice as much) as patients who see their GP in the Republic of Ireland.”  (based on Information obtained from BMA Northern Ireland, response dated 11.6.13 )

But poorer under 6s will need more healthcare than richer under 6s.

An interesting figure from GUI page 127 is the relative difference between GMS (public) and private patients usage of routine, free public health nurse check-ups and general practice nurse immunisation visits of 2.84 for GMS patients and 2.66 for private patients, which could indicate that if free routine health care is made available to the whole population, all sections of the community will take advantage of it. GUI itself indicates that the infants from higher social classes are more likely to receive their six-month vaccine on time.[xvii] A comparison of breast and cervical cancer screening rates depending on socio-economic group indicates better uptake of free routine care by the richer and healthier members of our community when it is available.[xviii] These figures just confirm the “Inverse Care Law” devised by Julian Tudor Harte in 1971. If universal care is made available to the population the richer in society will benefit from it disproportionately, particularly if healthcare distribution is left open to market forces.[xix]

But general practice does not just offer routine care but also acute episodic care, and surely the more deprived sections of the population will have greater need of this because of the greater rates of illness and lower life expectancy in these communities?

The British Medical Journal published a review of 1 million East London patients measuring general practice complex consultation usage based on income quintiles (lowest 20%, 20-40% incomes, etc) and made a very interesting discovery. In deprived areas attendance rates are much greater in the 30-70 year old age group, but remarkably similar attendance rates occur otherwise. It appears to suggest a concept that over a lifetime, poorer people develop chronic diseases at a younger age, engage with general practice more at a younger age and use up the same allotment of healthcare activity over a lifetime as richer people do but their lives are shorter so they consume it more quickly. The attendance rates over the age of 70 are similar probably due to a type of survival of the fittest in the most deprived areas.  This concept has never been considered in Ireland. [xx]

Minister Alex White stated in the Oireachtas that “research carried out for the Department in 2013 indicates that fee-paying children under 6 years of age have an annual GP visit rate of 2.7, whereas, medical card/GP visit card holding children in the same age cohort have an annual visitation rate of 3.1.”[i] This would not be consistent with 2008/09 UK QRESEARCH (audit of 4.3 million patients involving 21.7 million clinical consultations in the  UK) which predicts an attendance rate of 6.8 for the same age group for delivering a very similar service.[ii],[iii]  Applying longitudinal techniques to analyse data that follows the behaviour of individuals over time is very sophisticated and appears to be a good strategy, but it appears from the GUI results that is only works if it is applied to audit of clinical records rather than survey data.

The more recent Irish Government projected figures for extra GP consultations as a result of universal free general practice access appear to come from another analysis of GUI data. Its figures were presented at the 2014 annual meeting of the Association of University Departments of General Practice in Ireland (AUDGPI). It was stated at this conference “Based on an estimated population of 360,000 under sixes served by 2800 GPs, with 60% of these getting a medical card, an increase of 77 consultations per GP per year was estimate”. This figure supposes a new under 6s medical card figure of 216,000.

This is a common calculation mistake made by assuming that the national percentage of medical card patients is evenly spread over the whole population, forgetting that the over 65 year olds and particularly the over 70s population are disproportionately recipients of medical cards, resulting in the under 65 year old population having a much lower medical card eligibility that the national average.

My colleagues and I in 2014 in our paper on under 6s attendances stated that our “findings are based on a sample of over 1900 children and a total population comparable to Ireland’s national population in terms of proportion aged between 1 and 6 (7% versus 8% nationally) and GMS eligibility (34% versus 33% nationally)referencing Population and Migration Estimates (Accessed 22 February 2014) and the Primary Care Reimbursement Service STATISTICAL ANALYSIS OF CLAIMS AND PAYMENTS 2012.  

We calculated that the valid number of potential new under 6s patients would be the total April 2013 CSO estimation of the population of 432,320 and the total number of GMS patients were 173,780. This would leave 258,540 under 6s as non-GMS patients. However, a few percent of GMS entitled patients don’t have a valid GMS card at any one time so we decided to round down our original figure to 250,000 to give a more realistic number for the calculation of projected attendance rates.

IMJ 2014 data as it is missing the out of hours and telephone consultations in Table 2. This was as a result of a comment made in response to the IMJ  2013 paper at AUDGPI 2014, when it was suggested that as the out of hours/telephone data came from one practice, it should be separately represented. This is appearing to cause some confusion with the 2014 IMJ audit as it is being presented in the public as private patients attending twice per year and GMS patients five times per year when the out of hours and telephone consultations should be added to give figures of 2.7 and 5.8 for total private and GMS consultations.

Because the 2014 IMJ paper is an audit, it is not exposed to many of the non-sampling errors that affect the GUI survey.  ie. Errors that cause results that deviate from the true values in the population being surveyed. There is a potential sampling error due to the size of the doctor and patient population audited only representing about 0.6% of the national populations. However it does appear to reflect reliably CSO/PCRS data in terms of demographics so it is an accepted cost of ensuring that the data generated is reliable. Another downward bias in its figures would be as a result of its data collection which is retrospective and therefor only patients who are a year old or more can be included in the sample. It is true that private patients may have non-practice consultations elsewhere more than GMS patients increasing further the downward bias on the figures which would affect private more than GMS patients, but this is not something that can be measured by audit in Ireland. The the rounding down of both the national population and difference in attendance rate figure between GMS and private patients when making the final extra consultation figure of 750,000 as estimated by our paper is subject to further downward bias. Also, this study was retrospective and the new Under 6s contract potentially demands extra routine attendances at 2 and 5 years old and also the under 6s demographics have changed since the 2012/2013 population data was employed in the 2014 paper with Minister Varadkar claiming that there are not a potential 280,000 extra GMS patients. Both these factors will cause an increase in activity.

Considering the Irish data on routine care and UK data on all care; deprivation appears to affect the under 6 attendance rates much less than would intuitively be expected. There is also the potential that  in the short term, there might be a release of pent up demand that has developed between the announcement of free GP care and its actual delivery, resulting in a spike of attendances from new medical card patients after its initial introduction. Also, that with time, free GP care might induce a cultural change that promotes excess attendances. However we might not see the coalescing of more deprived and affluent patients attendance rates figures for a long time.

Considering all these biases with most of them causing a downward bias on the IMJ 2014 data and only the relative difference in attendance rates having an upward bias on it, it is very likely that the overall increased number of attendances of 750,000 as suggested by the IMJ 2014 paper is possibly on the conservative side.

Not only is the GUI data inconsistent with UK data (suggesting Irish patients attend their GP less than half the number of times UK patients do), GP visiting for private 9 month olds of 3.2 would also be totally inconsistent with the Health Protection Surveillance Reporting of childhood vaccination rates on 92% in this cohort, indicating most children have had 3 attendances for 2,4 and 6 month vaccination on top of possible free 2 week and 6 week baby checks through the Maternity and Infant Care Scheme. This results in most children having at least 3 but some up to 5 free routine GP attendances before any activity associated with illness is considered. [iv],[v]The GUI survey also claims 80% of 9 month olds visited their GP in the last 9 months but over 92% must have visited for at minimum one of their vaccinations.

Government commissioned GUI data analysis projects the figure of 77 extra consultations per GP per year as a result of universal free under 6 GP access. This is based on the number of GPs being 2,800 despite the government claiming that it only offered 2,413 contracts. (It is acknowledged that 2,800 figure is a more realistic assessment of the whole time equivalent GPs in clinical practice but that is another story)[vi] Government GUI analysis suggests that the population of new medical cards to be 60% of the rounded figure of 360,000 (clearly only the under 5, or 0-4 year old cohort and not the under 6 or 0-5 year old cohort) or 216,000 when the IMJ 2014 data, clearly calculates the population of potential new medical card patients to be a potential 258,540 and rounded it down to 250,000.

The government modelling suffers from massive underestimation of the under 6s population and over-estimation number of contracts being offered

Dr Kevin Denny uses mathematical modeling of GUI data and a reasonable assumption of 270,000 extra patients and 2,500 whole time equivalent GPs.

The problem with the GUI data caused by its 9 month or 1 year proxy recollection and the expected degradation of recollection of GMS more than private consultations that have not been corrected for, the assignment of practice nurse consultations to Public Health Nurse activity, its inconsistency with reliable UK data and multiple Irish audits including HSE audits of vaccine uptake. It clearly has too many non-sampling biases to be considered reliable for the purpose of projecting future workload.

I accept that Dr. Denny’s figures are a very sophisticated mathematical modelling of GUI data. The problem is that it does not relate in any way to real world of general practice activity. As the saying goes: junk in; junk out.

There are always going to be biases in any study, but non-sampling errors caused by asking the wrong question and degradation of recollection have a much greater effect that is consistently reproduced as is evident in surveys requesting one year recollection such as LIIS 2001, CSO 2007, 2010 and also the large-scale, nationally representative, longitudinal study on ageing in IrelandThe Irish LongituDinal Study on Ageing (TILDA) data when it is compared with 2001 CSO, IMJ 2013 which incorporates 2010 NUI Galway, 2006 Lifeways and QRESEARCH data.[vii]

Considering the BMJ 2014;349:g6814 article on how deprivation has minimal effect on children and young adults GP attendance in a universal free general practice system, and all the obvious methodological problems with the evidence used to support official figures for expected under 6 attendance rates, it is quite clear that it would be unwise to use government GUI analysis as that basis of informing significant changes in the national health system. Any minor methodological questions and potential biases that affect the IMJ 2013 and 2014 papers appear to cancel each other out particularly when the results are compared to other Irish and UK audits, or the 2001 CSO survey which only requires 2 week recollection.

 

Comments

comments

Author: Stephen Kinsella

Senior Lecturer in Economics at the University of Limerick.

19 thoughts on “A general practitioner’s perspective on the guest blog by Dr Kevin Denny”

  1. Any European observer, i.e the vast majority that take access to universal health care for granted, would view this debate with total amazement. David Quinn in the Indo nails it; inadvertently.

    http://www.independent.ie/opinion/comment/gps-must-fight-back-against-auction-politics-for-their-sake-and-for-ours-31313793.html

    GPs should be employees of the public health system OR in private practice; but not both! Ditto “private” beds in public hospitals.

    Ireland follows the Westminster model in matters of public administration and Harley Street when it comes to health. In Europe, the concept of a “consultant led” health service, for example, would be incomprehensible. There are GPs and medical specialists. That’s it! And the latter are called ‘doctor’ and not ‘mister’ in some form of archaic reverse medical snobbery.

  2. They say brevity is the soul of wit. Likewise, there is a lot to be said for keeping blog comments concise and to the point. Recall, the issue at stake here is: what is the effect of a change in price on the demand for a service, a common question in economics. There are numerous econometric analyses of this in general and a significant body that looks at this particular issue: the demand for GP services. Based on this, one can produce a guesstimate of the likely impact on the number of GP visits for children under 6 from the new policy. Before replying to specific points, I should state a qualifier: I have no vested interest in this issue. In addressing the points raised I face the significant constraint that Dr Behan appears to have a very limited knowledge of statistics and no economics whatsoever.
    In brief, Dr Behan thinks the numbers from his co-authored paper (Irish Medical Journal 2014) are the basis for extrapolating the effect and that mine are not.
    1) He argues that the GUI data is subject to recall bias. Unfortunately for him – and this is a crucial point- that does not imply that my results are wrong. If we were doing a simple multivariate regression (OLS) then classical measurement error in the dependent variable, of course, does not bias the coefficients. For the count data models that I used, adding a constant (say 3) has no effect on the estimated marginal effect i.e. if everyone understated their number of visits by 3. That’s a rather extreme example. Instead, I generated a random variable taking integers values distributed uniformly on the [0,5] range as a pseudo-measurement error in the dependent variable. This causes the marginal effect to FALL in any count data model- albeit very slightly. Using a [0,10] range doesn’t make much difference. So none of this supports Dr Behan’s arguments. Of course one trivially devise some form of non-classical measurement error which would lead to attenuation bias of any particular coefficient but I think the onus is on him to show that that is (or is likely to be) the case & that it is sufficient to render my results unreliable.
    2) The work that I reported uses standard techniques that have been used in the extensive literature on this subject and on modelling counts generally. That Dr Behan regards this as “very sophisticated mathematical modelling” is not a good omen. The dataset I used is one that has been collected at huge effort and expense by trained survey statisticians and other researchers (including medics) to be reliable and population representative. An international panel of 45 experts provide advice. There is no question that it is more representative of the population than data from a handful of GP’s practices about which we know nothing. Critically, GUI contains essentially all or most of the other variables we would need to estimate the relevant model.
    3) Behan et al’s data is administrative records from 6 GP practices. Although this implied a study size of 1931 these observations are not independent: they are clustered in the 6 GP practices. This is somewhat academic since, remarkably, the paper presents no inferential statistics and no descriptive statistics. We simply have no way of knowing how representative this data apart from the authors’ assertions to that effect nor can we draw any statistical inferences. Since the data is from patients who first attended practice more than a year previously and one in their lifetime, the authors are essentially sampling on the outcome so sample selection bias may be a feature: very healthy children are less likely to be included. How important this is empirically is hard to tell but it biases upwards the numbers. This is why you need to sample individuals. Comparing the mean number of visits between the two groups (with/without medical cards) might be useful as a descriptive exercise. However it tells you nothing about the effect of extending the medical card scheme to the general population for reasons that will certainly be obvious to anyone with a basic knowledge of economics or multivariate data analysis. Note that there is a lot to be said for using administrative data, as is common in the Nordic countries, but it needs to be sufficiently rich.
    4) In short
    a. If you want to know how many GP visits the relevant patients of those six practices had then their study is probably perfect.
    b. If you want to draw an inference about the average number of visits of such children (by medical card status) in the population it may or not be reliable, we have no way of knowing.
    c. Even if the estimate of the mean difference was population representative, if you want to estimate the effect of having a medical card on the number of visits then this study is useless.
    d. The presence of under-reporting does not invalidate the estimates reported by me (a paper is on the way).
    5) The GUI data is available from the Irish Social Science Data Archive. My Stata code is available on request.
    6) At this point, my marginal product is much higher doing other things so I won’t be reading or writing on this thread any further. Thank y’all.

  3. Check OECD Health at a Glance 2014 page 115 http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-europe-2014_health_glance_eur-2014-en#page117 Unmet need for a medical examination by income quintile – Ireland comes out as one of the best because general practice is run privately, but gives a private service to the oldest/poorest/sickest 42% of the national population greatly compensating for the inadequacies of the HSE run part of the health system.

    GUI data indicated that 0.2% of parents did not attend their GP when they thought that they should have because of financial reasons, which is very different to the figure of 27% private patients admitting that the cost of attending a GP made them think.

    David Quinns article is about the degrading of general practice for political purposes and the lack of association between resourcing and outcomes.

    Currently medical card patient get better general practice care because they are exposed to more preventative care and have easier access than private patients. Irish GP provides easier access and much more continuity of care from self employed GPs compared to the UK which are both associated with better overall outcomes at lower cost.

    Irish GP, running public and private costs at less then €750m / €17+ billion total health budget (OECD data http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT is missing €3b out of http://www.hse.ie/eng/services/publications/corporate/annualrpt2013.pdf Exchequer Revenue Grant €12.16b) which is unsustainable in the long term. Making all GPs employees will have the same damaging effect that Portugal health system has sustained from similar policy.

    Imagine if all GPs reduced their work capacity by 30% to step in line with HSE culture/regulations; it would knock out the greatest promoter of health equity in the country. Some GPs would then move to pure private, exacerbating the health inequity in this country.

    Health policy should be based of competent analysis of reliable statistics, not the promotion of folklore. You don’t want to ruin what works just because you don’t understand it.

  4. DOCM: it’s surgeons that are called mister because, as I understand it, they were originally barbers & this maybe why the barber pole is red and white.

  5. An interesting exercise at some point would be to ask a sample of the patients covered by the audit a version of the GUI question or to find some way of restricting the GUI data to the region audited or very similar regions. This would allow for a more clear way of separating between the sampling and non-sampling errors above. My reading of the reported behavioural frequency literature is also that there are good reasons for suspecting under-reporting due to forgetting particularly for proxy responses. However, the extent of this in different contexts depends on salience and many other factors and testing it would provide solid information and also also the GUI data to weighted accordingly. Consent from parents to link child survey data with actual medical records would also go a long way to resolving this issue.

    If the under-reporting were applying equally to covered and non-covered children then the implications for the original post estimates would not be fatal though it might still underestimate the effect of GMS due to well-known attenuation bias. Though if covered parents are indeed more likely to under-report then the estimates might heavily underestimate the effect of GMS depending on the size of this gap. I am not clear from the post how it is established that covered parents are more likely to under-report (point number 3) but this clearly would bias the estimates from a regression with coverage as an independent variable. It would be good to know more about the potential for differential reporting. Again, could be established very easily with an element of record linkage if that were possible.

  6. ..apologies “and also also the GUI data to weighted accordingly” should be “and also allow the GUI data to be weighted accordingly”

  7. Also for Wave 2 of GUI (which is what was used in the original post) the full question is below so it should be possible to address the issue of confusion between visit categories between public health nurse or practice nurse visits mentioned above provided the respondents understand the distinction. The fact that the question also includes telephone calls is also one for discussion.

    http://www.ucd.ie/t4cms/QUESTIONNAIRES%20-%20INFANTS%20-%20WAVE%202.pdf

    C8. In the past 12 months, how many times have you seen or talked on the telephone with any of the following about physical or emotional health? [INT: IF NONE THEN ENTER 0 – DO NOT LEAVE BLANK]
    a) A general practitioner (GP) …………………………………….. ______N
    b) A paediatrician / consultant / hospital doctor …………….. ______N
    c) A public health nurse …………………………………………….. ______N
    d) A practice nurse (i.e. a nurse in a GP’s surgery/clinic) . ______N
    e) A psychiatrist/psychologist …………………………………….. ______N
    f) Accident and Emergency …………………………………….. . ______N
    g) A social worker …………………………………………………… . ______N

  8. So called “free” GP care for ‘under 6s’ is a political, as distinct from a health demand, policy.

    Yet another ill-thought out ‘universal’ while numerous ‘particulars’ demand attention.

    PD inspired 2-tier system is disastrous.

    @William Behan

    Practitioner views are always welcome. Keep up the good work.

  9. “Consent from parents to link child survey data with actual medical records would also go a long way to resolving this issue.”

    I did discuss this with TILDA before and they correctly mentioned that they did not have patient permission to access their clinical records but it would be an option for the future.

    The problem is that Australia and the US employs the same 12 month recollection or in the case of the US with children sometimes 6 month recollection but does not specifically recognise visits with family physician

    http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf

    US makes reference to “Usual place of health care”
    and
    ‘‘About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about [child’s name]’s health? Include doctors seen while [he/she] was a patient in a hospital.’’

    despite a lot of reference to Charles Cannells work. So their answers are not really useful from as assessment of who is actually performing the healthcare.

    Regarding TILDA http://tilda.tcd.ie/publications/study-documents/
    a little problem was
    “HU005: In the last 12 months, about how often did you visit your GP?”

    which does not clearly identify telephone/out of hours and domiciliary consultations. Also the practice nurse consultations are not referred to, but I believe that has been corrected in the current wave of data collection (sign of true engagement with health professional colleagues).

    “I am not clear from the post how it is established that covered parents are more likely to under-report (point number 3)”

    Charles Cannell reports a lot about the quality of the recollection is based on the salience of the question and the method of its delivery.

    I said “The 2001 CSO National Quarterly Household Survey was performed on a population of 44,844 and used a 2 week recollection period for GP consultations.[vii] Living in Ireland Survey (LIIS) formed the Irish component of the European Community Household Panel (ECHP): an EU-wide project, co-ordinated by Eurostat, the statistical office of the European Union. The final LIIS was performed also in 2001 on a population of 6,521 adults and employed a 1 year recollection of GP consultations. The recollection figures for GP utilisation rates were 36% lower in the LIIS 1 year recollection than the CSO 2 weeks recollection, with public patients forgetting significantly more than private patients.

    All Patients GMS Only Private Only
    LIIS 2001 3.2 5.3 2.2
    CSO 2001 5.0 8.87 3.04
    Reduced Recollection % 36% 40% 28%

    (These are 2 separate samples reflective of the national population)”

    I have cleaned up the chart above and made an assumption that there was a greater degradation of recollection of GMS parents because that is what appeared to occur in the 2001 CSO 2 week recollection vs 2001 LIIS 1 year recollection

    I have done a small study linking patient recollection to their medical records and presented it at WONCA 2013 (Essentially world congress of family practitioners) https://twitter.com/DrWilliamBehan/status/609291373053890560

    but I am planning a much larger study with the TCD/HSE GP Training Scheme that will as close as mirror the 2015 CSO EHIS questionnaire, which I have got the very accommodating CSO to include a question about practice nurses just for the Ireland version.
    http://www.cso.ie/en/surveysandmethodology/health/irishhealthsurveyihs/

    However, there is still the obvious problems with GUI: Less than half the UK attendance rate despite the Irish population being more deprived (there are 2 other biases that might cancel each other out; it is harder to see a UK than an Irish GP but there are health visitors in UK practices that do no exist in Ireland) , degradation of recollection not corrected and also practice nurse visits counted as public health nurse visits.

    This is why I have concerns about its data being used and not about how it is processed after it has been produced.

  10. @ Kevin Denny

    Thanks for the clarification. You are right.

    https://www.rcseng.ac.uk/patients/the-surgical-team/qualifications-of-a-surgeon#three

    My point related, however, to the issue of the undue influence given to the concept of division between “junior” and “senior” i.e. consultant posts rather than concentrating on the distinction between “general” and “specialist” which would tailor qualifications to the requirement of the post. The idea of standardised grades has no place in modern medicine (or in any other area for that matter).

    That, and recognition that the decisive consideration for an equitable health system must be equality of access to care, are the two fundamental requirements for any real improvement.

    As the current debate reveals, neither is even on the horizon despite the fact that they are taken for granted in Continental Europe.

  11. Sorry on the above point – estimate errors would increase if there was a lot of measurement error on the dependent variable. Attenuation would happen, for example, if people were misreporting their status or there were issues in recording status. The key point is really whether there are differential reporting differences between groups and that is what would really stuff up the estimates. I think there is a case this might be happening but it seems really important for whoever is working on this policy to find this out.

  12. In case this thread looks even more than usual like a group of people is completely talking past one another I should point out there is a moderation queue so these comments were not posted, for the most part, sequentially.

  13. Well from the parent perspective I was reared to believe that wasting a doctor’s time was a mortler and take a very dim view of parents running off to the docs when their child is just puking or has a temp. So I think everyone should be charged something for a doctor visit. A fiver or a tenner for medical card patients, and maybe €20-25 for private patients. So I don’t need it to be free, but €50 is too much. My child got a mystery illness last year and I didn’t bring him for daaaaays hoping he’d get better. He was grand in the end, but when I ended up in Crumlin trying to explain to a consultant why I hadn’t brought him in sooner I had a major attack of the guilts and wondering why it’s prohibitively expensive to bring a child to the GP.
    However, if its free, free it is and I am deeply pissed off that our local doctor isn’t signing up. So I have to pay €50 and someone else goes for free? And how can I protest? It’s the country. It’s not like we’ve much choice. There is one doc 6 miles away whose signing up, so I think we should move to his practice.
    As someone has said, the problem here is mixing a private and public service under the one roof. It should be one or the other. I feel that my €50’s are subsidising the time wasters going for free.
    The GPs are negotiating with a gun to the head of their patients. *not happy about it* at all…

  14. Liam Delaney: Thanks for pointing out the delayed comments causing a disconnect in the debate

    You are right about Wave 2 of GUI having a different question to Wave 1: separating the practice nurse and PHN, but the government figures I was referring to employed wave 1 data from 2011.

    GUI
    Wave 1 Question (April 2011)
    H25 Since was born, how many times have you seen, or talked on the telephone with any of the following about physical health? (exclude at time of birth)
    IF NONE THEN ENTER 0 – DO NOT LEAVE BLANK
    A general practitioner (GP), or family physician ……………… ______N
    A paediatrician …………………………………………………………… ______N
    A public health nurse or practice nurse …………………………. ______N
    Another medical doctor (such as a hearing specialist) …… ______N
    Accident and Emergency or Outpatient ……… ………………. ______N

    http://www.ucd.ie/issda/static/documentation/esri/GUI-QuestionnairesInfants.pdf

    Practice Nurse/PHN question is then separated

    Wave 2 Question (May 2013)
    C8. In the past 12 months, how many times have you seen or talked on the telephone with any of the following about physical or emotional health? [INT: IF NONE THEN ENTER 0 – DO NOT LEAVE BLANK]
    a) A general practitioner (GP) …………………………………….. ______N
    b) A paediatrician / consultant / hospital doctor …………….. ______N
    c) A public health nurse …………………………………………….. ______N
    d) A practice nurse (i.e. a nurse in a GP’s surgery/clinic) . ______N
    e) A psychiatrist/psychologist …………………………………….. ______N
    f) Accident and Emergency …………………………………….. . ______N
    g) A social worker …………………………………………………… . ______N

    http://www.ucd.ie/t4cms/QUESTIONNAIRES%20-%20INFANTS%20-%20WAVE%202.pdf

    Regarding interviewing technique and patient recollection I use for reference:
    RESEARCH ON INTERVIEWING TECHNIQUES. Charles F. Cannell, Peter V. Miller, Lois Oksenberg, INSTITUTE FOR SOCIAL RESEARCH, UNIVERSITY OF MICHIGAN which is available at http://www.google.ie/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&sqi=2&ved=0CC0QFjAD&url=http%3A%2F%2Fxa.yimg.com%2Fkq%2Fgroups%2F23243091%2F728406173%2Fname%2Finterviewing%2Btechniques.pdf&ei=yAhVVKrMLo6p7Aa76oGgBg&usg=AFQjCNGgXqVG4CynbWyq8kDpJKPgy2EaoQ&sig2=pDFk748T7g7DgQIN8uoE4g&bvm=bv.78677474,d.ZGU
    which discusses responded bias and its affects

    There is a lot of evidence supporting the greater degradation of recollection with older patients and those who attend more which would indicate GMS patients.

    As I stated, The 2001 CSO National Quarterly Household Survey was performed on a population of 44,844 and used a 2 week recollection period for GP consultations. The final LIIS was performed also in 2001 on a population of 6,521 adults and employed a 1 year recollection of GP consultations. The recollection figures for GP utilisation rates were 36% lower in the LIIS 1 year recollection than the CSO 2 weeks recollection, with public patients forgetting significantly more than private patients.

    I know they were different populations, but I believe that my assumption does make sense

  15. kevin denny: Does your data pass the smell test and why are you predicting Irish GP attendance rates at half the UK attendance rates for this population?

    This is an economics debate, nobody outside the medical/health journalist/health statistics field will be aware of my work so it is up to me to show some kind of evidence to support my concepts, since they are obviously very alien to the health economics community at large.

    Econometric analyses that predict how a change in price affects services do not really related to the General Practice market because of the asymmetry of information that exists between the purchaser and consumer. In fact trying to promote a true market based environment for healthcare will just result in corporate cherry picking and prioritisation of the administration of healthcare over patient centred outcomes. That is why I have got involved in the debate.
    http://www.nejm.org/doi/full/10.1056/NEJMp1408009#t=comments
    http://www.nejm.org/doi/full/10.1056/NEJMp1501782#t=comments
    http://www.bmj.com/content/350/bmj.h904/rr-4

    I agree that my 2014 paper might not exactly predict the future attendance rate of the current private population, but there is a lot of international evidence to support a higher rate than the government is predicting, and my 2013 adult consultation prediction seems to be based on very sound grounds and reflects NI attendance rates. Also there is a lot of extra workload demanded by the new contract that could not possibly be measured by surveys of historic workload.

    Everybody’s figures are missing general practice nurse consultations, but I agree that this will have minimal effect on the marginal consultation difference because it is routine care and not acute episodic care. However, I expect that there is a much greater acute episodic under-recollection rate with GMS patients because they come more frequently, they don’t pay and the salience issues that accompanies that.

    Regarding the 45 experts who advise on GUI methodology; they clearly should be engaging with front line general practice more. A GP should not be able through correspondence be able to make changes on how the OECD calculates GP income (twice), OECD GP figures, PCRS summary of GP income per patient (and there is still a problem with the most recent figures – another days conversation) if there was reliable oversight. http://www.slideshare.net/DrWilliamBehan/biases-in-irish-health-service-statistics-w-behan-2014

    I do agree that my papers only look at 0.6% of the general practice workload in the country which does signify a potential bias, but 4 of the practices are GP training practices so it would be expected that the activity performed would be more likely to reflect standard practice. I have analysed our population and compared it to the CSO QNHS 2010 and most it to be more reflective of the most recent census than the QNHS. That is not including the fact that 62% of 2010 QNHS respondents are female.

    I disagree with the statement “the presence of under-reporting does not invalidate the estimates reported by me” because I believe that it will affect GMS more than private reporting rates

    Front line general practice has been effectively excluded from the healthcare debate since the 2003 Brennan report. It is quite obvious that managers and economists do not have the requisite skills to devise and run a health system due to the silo mentality and protection of vested interests that afflicts most public policy issues in Ireland. It is very important that reliable data be used in informing public policy. There is a lot of evidence that policy is being devised for general practice, then data is being manufactured to support it (my slideshare presentation above).

    This statement below is rather disappointing.

    “6) At this point, my marginal product is much higher doing other things so I won’t be reading or writing on this thread any further. Thank y’all”

    Cross fertilisation of ideas from different disciplines can only be of benefit to progress. However, if you don’t wish to engage, that’s fine. But please refrain from commenting on general practice issues in the future. It is well established that the health economics community is not interested in the measuring the extra value in terms of patient outcomes promoted by a patient centred mind-set, continuity of care, increased professional performance and self employed GPs as opposed to employees offering the service. However we do expect you to discuss more basic concepts such as workload and funding in a rational manner and not just support the groupthink that exists in this area.

  16. One of the few (and unforeseen) benefits of the partition of Ireland is that it is possible to make meaningful comparisons of different types of healthcare systems.

    R. Ireland and N. Ireland have fairly similar standards of living, climates, and lifestyles, but have markedly different systems of healthcare provision. The system in N. Ireland could have been designed by Karl Marx. The system in R. Ireland allows much more private sector provision.

    Since the mid-90s, mortality rates (adjusted for population age-structure) in R.Ireland have fallen much faster than in N. Ireland. Mortality rates in N. Ireland are now about 6% higher than in R. Ireland, which equates to almost 1,000 deaths annually in N. Ireland. The difference is most marked in age-group 35-65. Life expectancy in N. Ireland is now about 1 year less than in R. Ireland. Surveys like Slan (and its N. Ireland equivalent) indicate the population of N. Ireland is significantly more unhealthy than that of R. Ireland. For this, we have to thank socialist healthcare. I have a number of relatives who are GPs in N. Ireland. They all say the same thing. A huge amount of GP time is wasted on attending to minor illnesses that will cure themselves in a few days. No one should be deterred from seeing a GP if they think there is a serious problem, but people running to a GP and taking up 15 minutes of his/her valuable time everytime they sneeze is one of the clear downsides of N. Ireland’s socialist healthcare system.

    Bad and all as N. Ireland is, health in Scotland is much worse. As I’m sure Liam Delaney will confirm, mortality rates in Scotland are about 20% higher than in R. Ireland, while life expectancy is 2 years lower. Given the economic. social and cultural similarities between Scotland and R. Ireland, that tells us all we need to know about socialist healthcare systems.

  17. @William Behan

    ‘Cross fertilisation of ideas from different disciplines can only be of benefit to progress.’

    +1

    Life is inter-disciplinary.

    @Kevin Denny

    .

  18. @JohnTheOptimist

    http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_123.pdf explains well how healthcare only determines about 20% of the total health in society, but education, social circumstances, occupation etc

    I did a quick review of this on slide 2 of http://www.slideshare.net/DrWilliamBehan/dr-william-behan-national-primary-care-conference-nov-2014

    The US spend on health is particularly unproductive because it is not spend on self-employed GPs who have an on-going relationship with individual patients, but on activity in order to produce profits.

    I would question the concept that NI and Scotland are very similar societies to the ROI, I think that you will find that we are richer, many more of us have completed 3rd level education, we have better diets and less of us smoke.

    However, your point about GP access for sick people is impaired by an overloaded universal system; thus the opportunity cost of providing universal GP in Ireland is that poorest 42% of the population who are the sickest in the 30-70 y.o. age group that currently have same day/next day access have to wait longer to see a GP, not be able to maintain continuity of care and even might be displaced by a healthier population attending the GP instead of them, resulting in poorer outputs from the health system as a whole.

    The 2 seminal points of Julian Tudor Hartes ‘Inverse Care Law should be considered 1. The availability of good medical care tends to vary inversely with the need for it in the population served and also 2. That it operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

    Irish GP works disproportionately well considering its funding. Is that because we are offering a private quality system to public patients? Have any of our economists even considered the negative effect of making all the system public, allowing HSE standards to influence GPs more and then well know negative effect of diverting GPs from clinical activity into regulatory and system centred bureaucratic activity?

    Introducing universal GP to Ireland because it is what goes on elsewhere without acknowledging the benefits of the current system could be considered irresponsible. Particularly if it converts a relatively well functioning GP system into the primary care equivalent of 1,450 mini-Portlaoise Obstetric departments

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