Thérèse McDonnell and Eilish McAuliffe, UCD IRIS Centre, School of Nursing, Midwifery and Health Systems
This paper is available in pdf here.
The term “unscheduled” healthcare refers to care that is generally provided with less than 24-hour notice, with general practitioners (GPs) the most common first point of contact for this type of unplanned care (O’Cathain et al., 2007). The most significant change to paediatric unscheduled healthcare in Ireland in recent years has been the extension of free GP care to all children aged under 6 from July 2015. This policy provided access to daytime and out-of-hours (OOH) GP care at no charge to the 70% of children aged under 6 who were not existing holders of a medical or GP visit card[i], with GPs receiving an annual capitation fee per registered patient. While the removal of the barrier of cost might reasonably be expected to increase utilisation in the short-term, the longer-term impact on utilisation and possible health benefits needs to be better understood in order to inform future policy development.
Using data from eight practices and an OOH service in North Dublin, O’Callaghan et al. (2018) found attendance at daytime GP increased by 29% and by 26% at the OOH service in the year following the introduction of this policy, while Nolan and Layte (2017) using longitudinal data from Growing Up in Ireland, estimated an increase in attendance of 25%. Using data from 16 GP practices located across 12 of the 26 counties of the Republic of Ireland and a large OOH GP service operating in the South-East of Ireland, the CUPID Project assessed that this policy led to an increase in attendance at daytime GP of 20% – 21% in the three years following its introduction (McDonnell et al., 2022). A larger effect was identified at the OOH service (21% – 29%). Across each of these studies, the increase in attendance was significant and, as shown by McDonnell et al. (2022), persistent.
Impact on the Emergency Department (ED)
EDs also provide unscheduled healthcare, and EDs in many countries, including Ireland, are struggling to meet demand (Benahmed et al., 2012). Efforts to redirect low acuity patients to less costly primary care settings from busy resource intensive EDs rarely achieve sustained success. While not the primary aim of the extension of free GP care to under 6s, there is no evidence, as yet, that this policy is alleviating pressure on EDs (McDonnell et al., 2021, Walsh et al., 2019). It might be expected that the option of free care by a GP versus care at an ED at a charge of €100 might redirect many parents of young patients, particularly those presenting with low acuity conditions, to the care of GPs. It is also possible that parents requiring ED care for their child may attend their GP first to avoid this charge, with the €100 ED charge waived on presentation of a GP referral letter. However, the number of patients aged under 6 accessing the ED directly without a GP referral has not decreased and McDonnell et al. (2021) identified substantial variability in the overall impact of the policy across the five EDs in their study, with effects on attendance varying from no overall impact to an 29% increase in ED attendance by this aged cohort at a large hospital in Cork. Variation in the profile of the local population, local capacity constraints in general practice, regional variability in the GP to population ratio, and restricted hours of access to local GP services, may explain some of this variation.
Understanding the increase in attendance at GP
Previous research has identified that GP consultation charges in Ireland act as a deterrent to seeking healthcare. Amongst paying patients, the poorest and those with the worst health were most likely to defer attending their GP (O’Reilly et al., 2007). A nationally representative survey found that one in three respondents had previously decided not to attend their GP due to the cost (O’Dowd et al., 2017) and those without free primary care are more likely to report an unmet healthcare need (Connolly and Wren, 2017). Therefore, the increase in attendance following the introduction of free GP care may suggest previous unmet need, perhaps driven by those marginally above the income thresholds for an entitlement to a medical card or GP visit card.
Most acute illness consultations in children are for minor, self-limiting illnesses, and the likelihood of serious illness is less than 1% (Saxena, 2010). While data limitations meant that McDonnell et al. (2022) were unable to assess how this increased attendance at GPs varied by acuity or presenting complaint, GPs participating in a qualitative study conducted with a sample of 16 GPs (McCombe et al., 2019) reported that, following the introduction of the Under 6 policy, more children from this age cohort were attending with minor symptoms and illnesses at an earlier stage of evolution, with some parents attending immediately upon the onset of symptoms, no longer adopting a wait-and-see approach. GPs interviewed by McCombe et al. (2019) also noted that the increase was more keenly felt in out-of-hours, with more working parents now accessing this service for their young child in the evenings and on Sundays.
A discrete choice experiment (DCE) conducted by the CUPID Project (Nicholson et al., 2022) provides further insight on the attributes of unscheduled healthcare services for their children that were most important to parents. Data collected from a sample of 458 parents in Ireland elicited their preferences across five attributes: timeliness, appointment type, healthcare professional attended, telephone guidance prior to attending, and cost. While all attributes were statistically significant (a mixed logit model was used), same-day or next-day access, coupled with care by their own GP, were identified as the strongest preferences of parents accessing unscheduled healthcare for their children. Therefore, when a parent decides they need to access healthcare for their child, many do not want to wait. A qualitative study of parents also conducted by the CUPID Project (Conlon et al., 2021) identified that, for parents working full-time who were dependent on childcare, working hours and health policies implemented by childcare facilities were an additional consideration. Many crèches attach conditions to a sick child’s return, for example a child taking an antibiotic may not be permitted to return to the crèche for at least 48 hours following commencing the antibiotic course. Therefore, a sick child at the weekend often results in parents seeking care by an OOH service rather than waiting for a GP appointment on the following Monday, and therefore delaying the child’s return to day-care. The removal of a charge to access this service may result in this being a more accessible option for many working parents.
This DCE and the supporting qualitative research on parental health-seeking behaviour when accessing unscheduled healthcare (Conlon et al., 2021), illustrates how circumstances and preferences result in parents’ accessing OOH GP care or the ED when their own GP is not available. Conlon et al. (2021) also found that parents considered the appropriateness of seeking healthcare, and their decision-making was informed by their experience as a parent, perceived urgency, and need for reassurance (Conlon et al., 2021). Indeed, O’Regan et al. (2018) conducted a study across 72 GP practices before the introduction of free GP care for children under six and assessed that reassurance was the action documented by GPs in 54% of the most recent consultations with children aged between 1 and 14 years. However, with 60% of consultations also resulting in prescribing, reassurance alone was not the sole outcome for many of these consultations.
Health benefits of free GP care
Better access to primary care, if this translates into timely and effective management of health conditions and preventative care, should improve health, and in turn reduce future healthcare utilisation (Einav and Finkelstein, 2018, Jatrana and Crampton, 2021). However, findings on the impact of improved access to healthcare on health outcomes vary, and most studies find no short- or medium-term significant health benefits from increased accessibility (Currie et al., 2008, De La Mata, 2012, Taubman et al., 2014). However, viewed over a longer timeframe, there is evidence of a positive impact of sustained accessibility and regular use of medical care on health outcomes (Currie et al., 2008, Miller and Wherry, 2019). The Under 6 policy includes the provision of periodic wellness checks for children, which are focused on health, wellbeing and disease prevention, at ages two and five. Also included, with an additional fee to the GP, is an assessment visit for a child with asthma and an annual review visit starting in the year of registration on the Asthma Cycle of Care programme. With 10% of children in Ireland suffering from asthma, and with 40,000 of children now registered under this programme (Asthma Society of Ireland, 2019), these measures will lead to higher attendance at daytime GP, but also have the potential for long-term health benefits for many children.
The challenge of future expansions
Children aged under six are more frequent attenders at GP compared to older children (McDonnell et al., 2022). Should this policy be extended to older children, the increase in the number of visits would be relatively less severe due to lower attendance rates by this older cohort (Health Service Executive, 2015). Nonetheless, the cumulative effect on demand for GP consultations would be substantial. It is important that access to quality GP care is preserved, and GPs have expressed concern that the policy has resulted in less availability of appointments in general, with some GPs introducing waiting lists to take up cancelled appointments due to high demand (McCombe et al., 2019). Over one third of GPs in Ireland are aged over 55, with some unable to retire due to the lack of a replacement, particularly in rural areas (Houses of The Oireachtas, 2019). Therefore, the pace of change needs to be realistic, with further entitlement expansion linked to capacity building (Thomas et al., 2021).
While there is an urgent need to increase the number of GPs (Health Service Executive, 2015), there are health system improvements that could help meet growing demand. The Sláintecare plan includes the aim of providing universal access to a range of primary care services (Houses of The Oireachtas, 2017). Many patients currently face delays in accessing primary care services such as physiotherapy, speech and language therapy, and mental health supports (Health Service Executive, 2020). GPs are unable to obtain timely referrals for patients, and therefore continue to treat patients of all ages who should be supported by other parts of the health system. Greater investment in these services and improved access is needed. Furthermore, the availability of diagnostics such as x-ray, ultrasound and MRI in a primary care setting would require investment but could result in greater efficiencies and access for those in need (O’Dowd et al., 2017). Improved funding and training of practice nurses could also ensure GP time is spent efficiently (O’Dowd et al., 2017). The widespread adoption of remote consultations during the COVID-19 pandemic ensured the provision of accessible healthcare at a challenging time. With perceived urgency and the need for reassurance often driving a parent’s decision to seek healthcare for their child (Conlon et al., 2021, Nicholson et al., 2020), this model of care might provide an accessible option for parents seeking reassurance and guidance. Indeed, approximately 20% of calls to the OOH service in McDonnell et al. (2022) were triaged by a nurse by telephone without further need for a consultation with a GP.
It will be important to monitor how this policy impacts child health over the longer term. That said, current data systems, particularly in primary care, make assessing the impact of policy initiatives challenging, and this needs to be addressed if future policy developments are to be robustly evaluated. The absence of a national platform for collating GP patient-level data presents a challenge to health researchers and requires the commitment of GP and research resources to supporting individual research studies. Data extraction must be carried out at individual practice level, requiring the dedication of significant research resource to recruiting and liaising with practices, and to designing appropriate tools that can extract records in a non-disruptive and GDPR compliant manner. Variability in the coding of patient level data, such as diagnosis, within and across practices, significantly limits evaluation. Furthermore, the in-ability to connect patient records across primary and secondary care is a major barrier to insightful healthcare evaluation. While the future success of eHealth and rollout of individual health identifiers (IHI) in particular (eHealth Ireland), should lead to improvements in patient safety and care, it will also facilitate research that addresses questions of efficiency and policy evaluation.
The introduction of free GP care for children aged under six has alleviated the financial burden of accessing unscheduled healthcare for many parents of young children, and this policy has the potential for long-term health benefits. However, this policy has added considerably to the demand for GP consultations, with no compensating decrease in attendance at EDs (McDonnell et al., 2022). Prior unmet need, the provision of additional assessments to children aged under six, parental response to a service at no charge, and rerouting of access to the ED through GPs by some parents, may all contribute to this increased demand. This policy change in 2015 was viewed as an initial step in the transition from a mixed public and privately funded health system to a system of universal healthcare (Department of Health, 2019). However, a more integrated policy of boosting the supply of GPs and initiating improvements to the wider health system as described under the Sláintecare plan is necessary, particularly in the context of future expansion, if the health benefits anticipated from the introduction of this policy are to have a realistic chance of being realised. The move to universal healthcare is a complex process that would benefit from timely and rigorous analysis of the impact of policy changes to inform each subsequent stage of the process. Significant improvements in the quality and interoperability of datasets is needed for this to happen.
ASTHMA SOCIETY OF IRELAND. 2019. Asthma Facts and Figures. [Online]. [Accessed].
BENAHMED, N., LAOKRI, S., ZHANG, W. H., VERHAEGHE, N., TRYBOU, J., COHEN, L., DE WEVER, A. & ALEXANDER, S. 2012. Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium. European journal of pediatrics, 171, 1829-1837.
CONLON, C., NICHOLSON, E., DE BRÚN, A., MCDONNELL, T. & MCAULIFFE, E. 2021. Stuff you think you can handle as a parent and stuff you can’t’. Understanding parental health‐seeking behaviour when accessing unscheduled care: A qualitative study. Health Expectations, 24, 1649-1659.
CONNOLLY, S. & WREN, M.-A. 2017. Unmet healthcare needs in Ireland: analysis using the EU-SILC survey. Health policy, 121, 434-441.
CURRIE, J., DECKER, S. & LIN, W. 2008. Has public health insurance for older children reduced disparities in access to care and health outcomes? Journal of health Economics, 27, 1567-1581.
DE LA MATA, D. 2012. The effect of Medicaid eligibility on coverage, utilization, and children’s health. Health economics, 21, 1061-1079.
DEPARTMENT OF HEALTH 2019. Health in Ireland, Key Trends, 2019.
EHEALTH IRELAND. Individual Health Identifier (IHI) [Online]. Available: https://www.ehealthireland.ie/a2i-hids-programme/individual-health-identifier-ihi-/ [Accessed 28 April 2022 2022].
EINAV, L. & FINKELSTEIN, A. 2018. Moral hazard in health insurance: what we know and how we know it. Journal of the European Economic Association, 16, 957-982.
HEALTH SERVICE EXECUTIVE 2015. National Doctor Training and Planning (2015). Medical_workforce_planning_future_demand_for_general_practitioners_2015-2025.
HEALTH SERVICE EXECUTIVE 2020. Annual Report and Financial Statements 2019.
HOUSES OF THE OIREACHTAS 2017. Committee on The Future of Healthcare
HOUSES OF THE OIREACHTAS 2019. Dáil Eireann Debate, General Practice Service Provision.
JATRANA, S. & CRAMPTON, P. 2021. Do financial barriers to access to primary health care increase the risk of poor health? Longitudinal evidence from New Zealand. Social Science & Medicine, 288, 113255.
MCCOMBE, G., CONNEALLY, N., HARROLD, A., BUTT, A. F., BEHAN, W., MOLONY, D. & CULLEN, W. 2019. How does the introduction of free GP care for children impact on GP service provision? A qualitative study of GPs. Irish Journal of Medical Science (1971-), 188, 1245-1249.
MCDONNELL, T., NICHOLSON, E., BARRETT, M., BURY, G., COLLINS, C., CUMMINS, F., DEASY, C., DENNY, K., DE BRÚN, A. & HENSEY, C. 2021. Policy of free GP care for children under 6 years: The impact on emergency department attendance. Social Science & Medicine, 279, 113988.
MCDONNELL, T., NICHOLSON, E., BURY, G., COLLINS, C., CONLON, C., DENNY, K., O’CALLAGHAN, M. & MCAULIFFE, E. 2022. Policy of free GP care for children under 6 years: The impact on daytime and out-of-hours general practice. Social Science & Medicine, 296, 114792.
MILLER, S. & WHERRY, L. R. 2019. The long-term effects of early life Medicaid coverage. Journal of Human Resources, 54, 785-824.
NICHOLSON, E., MCDONNELL, T., CONLON, C., DOHERTY, E., DEBRUN, A. & MCAULIFFE, E. 2022. Parent’s preferences for unscheduled paediatric healthcare: A Discrete Choice Experiment. Under review.
NICHOLSON, E., MCDONNELL, T., DE BRÚN, A., BARRETT, M., BURY, G., COLLINS, C., HENSEY, C. & MCAULIFFE, E. 2020. Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare–systematic review. BMC health services research, 20, 1-23.
NOLAN, A. & LAYTE, R. 2017. The impact of transitions in insurance coverage on GP visiting among children in Ireland. Social Science & Medicine, 180, 94-100.
O’CATHAIN, A., KNOWLES, E., MUNRO, J. & NICHOLL, J. 2007. Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys. BMC health services research, 7, 1-7.
O’REILLY, D., O’DOWD, T., GALWAY, K. J., MURPHY, A. W., O’NEILL, C., SHRYANE, E., STEELE, K., BURY, G., GILLILAND, A. & KELLY, A. 2007. Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional survey. The European journal of general practice, 13, 231-236.
O’CALLAGHAN, M. E., ZGAGA, L., O’CIARDHA, D. & O’DOWD, T. 2018. Free children’s visits and general practice attendance. The Annals of Family Medicine, 16, 246-249.
O’DOWD, T., IVERS, J.-H. & HANDY, D. 2017. A future together building a better GP and primary care service.
O’REGAN, A., CULLEN, W., O’GORMAN, C., HICKEY, L., O’NEILL, E., O’DOHERTY, J. & HANNIGAN, A. 2018. What effect do point of care fees have on childhood consultations in general practice? BMC health services research, 18, 1-7.
TAUBMAN, S. L., ALLEN, H. L., WRIGHT, B. J., BAICKER, K. & FINKELSTEIN, A. N. 2014. Medicaid increases emergency-department use: evidence from Oregon’s Health Insurance Experiment. Science, 343, 263-268.
THOMAS, S., JOHNSTON, B., BARRY, S., SIERSBAEK, R. & BURKE, S. 2021. Sláintecare implementation status in 2020: Limited progress with entitlement expansion. Health Policy, 125, 277-283.
WALSH, B., NOLAN, A., BRICK, A. & KEEGAN, C. 2019. Did the expansion of free GP care impact demand for emergency department attendances? A difference-in-differences analysis. Social Science & Medicine, 222, 101-111.
[i] See McDonnell et al., 2022 for an explanation of eligibility criteria for a medical or GP visit card.