Editorial: Fishhooks in cheap GP plan

Governments have been talking forever, it seems, about bulk-funding doctors in general practice. The idea has been variously known as "capitation","budget holding" and "population-based funding." By any name, the idea has been that the state will pay general practices a periodic grant based on the number of people each serves, with an additional loading for those serving predominantly poor or needy populations. The practices were to be given considerable discretion to apportion their fund as they saw fit.

But that last element seems to have disappeared in the latest proposals circulated to practitioners and reported on our front page yesterday. Primary health organisations, as the bulk-funded practices are to be called, will have to be willing to charge little or no fee to all their enrolled patients if they sign with the scheme.

So those with more than half their roll consisting of Maori, Pacific Islanders or holders of the community services or high-use cards, will receive a higher subsidy from the state. But those of their patients who do not fit those categories of need must be treated on the same basis. No wonder the Medical Association is worried that well-off people will migrate to practices that qualify for the higher subsidy.

Whatever happened to the idea that primary health providers could decide who among their patients had greater need of public funds? It probably disappeared with the advent of this Government. Labour seems not to subscribe to the view that public spending is best allocated by those closest to the needs. It is reducing the decision-making autonomy of school boards, universities and hospital authorities, and primary health care is to be no exception.

The only reason the Government wants to bulk fund primary health organisations (PHOs) is that it wants to treat "populations" as much as individuals. And in particular it wants to get rid of the community services card, the device by which individuals can get access to doctors at a reduced rate. Why, you might ask?

The card has been in use for a good few years and it has not carried the stigma that the Labour Party predicted when the previous Government proposed it. Pensioners, students and low-income households readily acquire the card if they qualify for it and there have been no reports of embarrassment or reluctance to use it. It is far preferable to a system in which health providers would have to means test their patients - as the latest subsidy proposal acknowledges. PHOs will qualify for extra funds if more than half their patients carry the card.

That, though, is to be an interim arrangement. The Government looks forward to the day when it can afford to ensure everybody can visit the doctor at little or no charge. The draft scheme now circulating for professionals' comment envisages that the card can be phased out within 10 years. Do not hold your breath.

Labour Governments haven been trying to introduce free primary health services since 1936. For all that time general practitioners have insisted on retaining their right to charge a fee. As Health Minister in the last Labour Government, Helen Clark could not get doctors to agree to subsidy contracts that would remove that right. As recently as the mid-1990s, when New Zealand First tried to institute free doctors visits for children under 6, doctors ensured they retained discretion to charge.

About a third of general practices are organised for bulk-funding and most others sound well-disposed to the public health programmes it will suit. But there is unlikely to be a practical substitute for charges and subsidies based on individual treatment. People, not populations, get sick.