Free Children’s Visits and General Practice Attendance

INTRODUCTION

Visitation rates are influenced by the way health care is financed.^1,2 In the Republic of Ireland, 55% of all citizens do not qualify for state-funded, means-tested general practitioner care³ and thus must pay out-of-pocket fees (approximately US$50 to US$65) for each general practice visit.⁴

On July 1, 2015, all 440,000 children aged younger than 6 years in the Republic of Ireland were granted free access to general practice visits, regardless of parental income.^5,6 This policy change allowed 300,000 additional children free visits to both daytime and out-of-hours care settings.⁶

The primary aim of this study was to use general practice electronic health records to analyze changes in daytime and out-of-hours service use since implementation of the new policy.

METHODS

We used anonymized retrospective visit data from general practice electronic health record systems. Ethical approval for the study was obtained from the Trinity College Dublin/Health Service Executive General Practice Training Scheme Ethics Committee.

RESULTS

Table 1 shows general practice visitation data for both the daytime and out-of-hours settings. Comparison of the periods before and after the policy change showed significant increases in both numbers of patients and numbers of visits by children aged younger than 6 years, in daytime and out-of-hours settings alike (P <.001 for all). Figure 1 shows changes over time in number of visits per month for this age-group.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Temporal pattern of monthly general practice visits by children aged younger than 6 years.

DISCUSSION

Introduction of free general practice care for all children aged younger than 6 years led to a significant, if predictable, rise in the number of children seen free of charge and a sharp fall in the number paying out of pocket. The out-of-pocket number did not drop to zero, however, as some parents used general practice services before completing the application process for free visits. Overall, 9% and 20% more children attended the daytime and out-of-hours services, respectively, at least once in the year after the policy change.

Number of visits by children aged younger than 6 years increased in both settings by more than 25%. After the granting of free care, the overall visitation rates for children younger than 6 years approached that of those seen free of charge before the policy change. Although both the daytime and out-of-hours services saw more patients of all ages in the period after the policy change, children aged younger than 6 years accounted for a disproportionate increase in service use: 45% and 73% of the additional visits in the year after the policy change to the daytime and the out-of-hours services, respectively, were by children this age.

The birth rate dropped by 3% over the study period⁸ and numbers of general practitioners employed in each setting were similar throughout the study. In addition, although seasonal variation was seen as usual (Figure 1), there were no notable disease outbreaks in North Dublin during the study period that otherwise might explain increased service use. Further research is needed to establish whether severity of medical issues changed when access was free and whether increased workload had effects on general practitioners and patients.

Demand for general practice services is increasing worldwide, both in daytime settings^9,10 and out-of-hours settings.^11,12 Equitable access should be a cornerstone of any health care system, but making services available free of charge inevitably increases service use. In the Republic of Ireland, there are already indications that the general practitioner workforce may struggle to meet demand in the near future,^13,14 so future plans to extend state-funded general practice care to all groups¹⁵ will require careful workforce planning.