RE: Free Children’s Visits and General Practice Attendance

This retrospective audit of changing GP workload in response to the elimination of GP fees appears to be a well-planned and implemented piece of research. However, there are 2 methodological errors in the published “Visit Per Patient” calculations for each demographic in Table 1. that are repeated in both the abstract and body of the article. The workload figures published in this paper have been referenced in the national healthcare debate and have the potential to adversely influence Irish healthcare policy.1,2 Thus, it is only proper that these errors should be highlighted and corrected.

Average visitation rates should be calculated by dividing the total number of visits generated by a population by the total reference population. This methodology has previously been used by Irish Central Statistics Office surveys 3,4,5 as well as a previous Irish audit of GP workload 6 when calculating average GP attendance rates. Calculations of visiting rates should not just include patients who have attended in the previous 12 months when there is data available on the number of patients who did not attend. Nor should average visiting rates in year 2 be asymmetrically diluted by fully counting all patients in the denominator of the calculation when they only attended for a portion of the year in each of the categories.

The first set of calculation errors produced by the authors were the figures for GP visiting rates for the different populations. The published visiting rates were calculated from the raw data of who attended in each individual year of the study. This missed both public and private patients who did not attend in either year, causing an increase in the calculated visiting rates above the true population rates. Each Irish GP practice has reliable population data on their total ‘free of charge’ patients but not their ‘out of pocket’ patients. More significantly, they also did not include private patients in their ‘before’ visit rate who did not attend in year 1 but did attend in year 2 of the audit, which had the effect of inflating the year 1 fee paying patients visit rates. This has resulted in compressing the difference between the year one fee-paying and non-fee paying patients’ attendance rates as free access patients are more likely to attend their GP at least once in any year. 4,5

Nationally the increase in the under 6 years old population that applied for access to free healthcare (GP Visit Card(GPVC)) followed an inverse logarithmic pattern. 7,8,9 (Figure 1.)

Figure 1.

The second set of calculation errors were signposted by producing in Table 1. a ‘Year After Policy Change’ ‘Daytime’ ‘Total’ ‘Visits per Patient’ figure that is in excess of both the separate corresponding ‘Out of Pocket’ and the ‘Free of Charge’ visiting rates. The combination of 2 different visiting rates should never generate a larger figure for a combined average rate. This analysis error predominantly affected the visiting rates for year 2 and was produced by fully counting the same patients twice in both the numerator for fee-paying and also non-fee-paying patients. It resulted in reducing the visiting rates for both populations. Most of the national year 1 fee-paying population who attended year 2 moved to non-fee paying early in the year after the policy change. Figure 1. Not considering this eligibility migration in the calculations predominantly diluted the year 2 fee-paying patients visit rates. Using whole year weighted populations as the numerator, which this assessment calculates from nationally available data, would have provided more reliable and on cursory examination of this corrected table 1., plausible visiting rates for the different year 2 ‘out of pocket’ and ‘free of charge’ populations.

Modified Table 1 only displays the original paper’s under 6 year old figures along with the corrections of both the ‘Patients’ populations and ‘Visits per Patient’ as per the above analysis. Year 2 population weighting is extrapolated from published Irish health service national data. 7,8,9 (Figure 1.) The ‘Visits per Patient’ corrections that have been made in this modified Table 1. do not take into account patients who did not attend the GP in both years of the study which has the effect of reducing the patient populations and inflating the visiting rates. The inflated population by patients from other practices transiently attending study practices is also not taken into account nor is the dilution of workload effect of practice patients attending elsewhere during the study period and non-practice patients infrequently attending. General Practice nurse activity, which delivers most of the primary immunization vaccines in the under 2 years old population, is not included in this audits data collection. Telephone consultations appear to be not included in the data collection.

This is an important study with reliably collected data which can inform national and international debates on health policy development concerning evolving national Family Physician access. Any errors in this paper appear solely to be at the visiting rate calculations and writing stages. Allowing the above appropriate corrections to be flagged would more reliably reflect the original data in an informed context.

References

1. Murphy M, Lecturer in General Practice, Royal College of Surgeons in Ireland. Opinion, Irish Times, 9th January 2020. Doctors should welcome free GP care for children (irishtimes.com) On the 10th January 2020 the Irish Minister of Health, Simon Harris TD also referenced this papers suggestion of the lack of difference between fee-paying and non-fee-paying patients visit rates on a current affairs program on RTE1, the national broadcast TV station.

2. Behan W, General Practitioner, Dublin 12. Letter Irish Times on ‘Free GP care for children’ 11th January 2020. https://www.irishtimes.com/opinion/letters/free-gp-care-for-children-1.4136146

3. Module on Health, Quarterly National Household Survey, Quarter 3 2001. Central Statistics Office, Ireland. https://www.cso.ie/en/media/csoie/qnhs/documents/qnhshealth.xlsx

4. Health Status and Health Service Utilisation, Quarterly National Household Survey, Quarter 3 2007. Central Statistics Office, Ireland. https://www.cso.ie/en/media/csoie/releasespublications/documents/labourmarket/2007/healthstatusq32007.pdf

5. Health Status and Health Service Utilisation, Quarterly National Household Survey, Quarter 3 2010. Central Statistics Office, Ireland. https://www.cso.ie/en/media/csoie/releasespublications/documents/labourmarket/2010/healthstatusq32010.pdf

6. Behan W, Molony D, Beam C, Cullen W. Are Irish Adult General Practice Consultation Rates as Low as Official Records Suggest? A Cross Sectional Study at Six General Practices. Ir Med J. 2013 Nov-Dec;106(10):297-9 http://archive.imj.ie/ViewArticleDetails.aspx?ArticleID=13077

7. CSO Population PEA11. Population estimates from 1926, Single Year of Age. https://www.cso.ie/en/statistics/population/populationandmigrationestimates/

8. Health Service Executive Primary Care Reimbursement Service Publications Reporting and Open Data PCRS - Reporting Menu (sspcrs.ie)

9. Smyth B., Marsden P., Donohue F., Kavanagh P., Kitching A., Feely E., Collins L., Cullen L., Sheridan A., Evans D., Wright P., O'Brien S., Migone C. (2017) Planning for Health: Trends and Priorities to Inform Health Service Planning 2017. Report from the Health Service Executive. ISBN 978-1-78602-037-6 https://www.hse.ie/eng/services/news/newsfeatures/planning-for-health/planningforhealth.pdf