Significant numbers of people who qualify for GP visit cards are failing to take up the offer. Niamh Cahill reports
Why are hundreds of thousands of people, who are entitled to a GP visit card (GPVC), not applying for them?
In September 2023, ‘free GP care’ eligibility was extended to around 500,000 adults and children. But more than a year later, it is believed that almost 400,000 people have not taken up the offer.
GPs themselves believe the main barrier has been the complicated application process. Indeed, Minister for Health Stephen Donnelly has sought to simplify the system to improve uptake.
However, a HSE spokesperson told the Medical Independent (MI) that market research aimed at understanding motivations and barriers found the most common issue was “eligibility perception”.
The spokesperson said over half of respondents believed they would not qualify for a GPVC based on their income.
Many of those on ‘median household incomes’ are entitled to a GP visit card following last year’s eligibility expansions.
If HSE’s market research is to be believed, those eligible are unaware of their entitlement. Yet GPs have argued that even when patients are informed of their right, many still fail to sign up.
Data
According to a recent HSE report, around 42 per cent of the population now have access to free GP care on foot of several policy initiatives.
A central commitment in the Programme for Government is that individuals have access to “healthcare in the right place”, according to a spokesperson for the Department of Health.
The first major expansion came in 2015 when free GP care was provided to all children aged under six, which resulted in a significant increase in general practice workload.
Adjustments to the median income thresholds in the 2023 GP Agreement with the IMO enabled 430,000 adults and 71,000 children (under eight years old) to receive free GP care in September and August, respectively. Without these changes, they would have needed to visit their GP on a private basis.
The Government introduced these measures for varying reasons, including the need to alleviate growing pressure on secondary care services.
The GPVC covers the cost of GP visits only, as opposed to the medical card, which covers a wider range of healthcare costs.
The Department of Health spokesperson outlined that “access to GP visit cards and medical cards removes the burden on people who may defer necessary medical services because they cannot afford it”.
But GPs have not noticed a direct link between an increase in workload and the eligibility changes introduced last year, as they did in 2015.
As of September 2024, almost 700,000 (696,531) people in Ireland had a GPVC and a further 1.5 million people had medical cards, according to HSE data.
GPVC data held by the HSE Primary Care Reimbursement Service (PCRS) shows that the number of GPVCs increased by only 117,000 between September 2023 and September 2024. This is despite the fact eligibility was opened up to a further 500,000 adults and children.
The HSE and Department of Health failed to provide data on how many people, who must undergo a means test, have taken up GPVCs since the changes were introduced last year.
How it works
Currently, children aged under eight, individuals over 70, and those in receipt of carer’s benefit or carer’s allowance, can apply for a GP visit card without any means test.
Those aged eight to 69 must undergo a means test where their income, expenses and personal circumstances are assessed. An online application portal is available at www.hse.ie.
If a family’s income after expenses is below a certain financial threshold for their family size they may qualify, according to the HSE.
On its website, the HSE provides detailed examples of those who could qualify for a card, such as a married couple with two children and a single parent with one child.
Lots of information is taken into account during the assessment process, including but not limited to: Mortgage payments; childcare costs; rent payments; income from savings and investments; pension; rental income from family home; property other than the family home; and travel to work costs.
Recipients must be below a qualifying financial threshold. This is calculated by adding a basic rate or amount of money depending on your circumstances, an amount for each dependent, and your allowable expenses.
Last year, when the changes were announced, Mr Shaun Flanagan, HSE Assistant National Director, PCRS, said: “The HSE would encourage all those who think they may be eligible to apply. It’s important to remember that you could qualify even if the amount of money you earn is high and if your expenses are also high. Your application will be means-tested, and you will be asked to self-declare your income and allowable outgoings.
“When you apply, you should have your [personal public service] number, income and expense details, marital status, [date of birth] and details on any children dependent on you to make it easier for you. Remember the quickest and easiest way to apply for a GP visit card is online.”
Minister Donnelly said last year: “You may think you do not qualify, but the application process factors in household expenses such as mortgage or rent and childcare, along with income. With the increases in income threshold, now close to half of households in Ireland could be eligible for free GP care.”
“The HSE have put in place a simplified online application process which is easier and faster to complete. I encourage everyone to go online, find out more, and apply.”
According to the HSE spokesperson, GPVC applications are being processed within 15 working days while emergency applications are generally processed within 24 to 48 hours.
The Department of Health has published examples of the types of households that would qualify for a GP visit card.
I give them advice and the link to apply and they still don’t apply
GP views
GPs who spoke to MI believe awareness is a major factor in poor uptake.
But even when GPs make patients aware of their entitlement, many still fail to apply for the card, according to Dublin GP
Dr Ray Walley.
“I have people who delay coming to the doctor and I know they would fit into the bracket. I tell them they are eligible. I give them advice and the link to apply and they still don’t apply. I don’t know whether or not the paperwork involved is complicated or extreme,” Dr Walley told MI.
“I think the problem with modern life is everyone is extended, everyone is flat out, and people only see the relevance of it when they are sick.”
Dr William Behan believes any administrative barrier, such as a means test, will always have a negative impact on uptake.
The Dublin GP told MI that “universal entitlement based on age group might not be the most equitable, but it should generate the highest uptake”.
According to Kerry-based GP Dr Eamonn Shanahan, the low uptake has taken GPs by surprise.
“What is surprising is how few have taken them up. I haven’t observed a surge in doctor visit card [DVC] patients. The problem is for patients to get the GP visit card, it’s not automatic. They have to make a statement of means and people are reluctant to do that,” he said.
“I retired from the GMS two years ago, but I do know that there hasn’t been any huge surge in patients overall, looking at our numbers at the practice, since the changes were introduced,” Dr Shanahan said.
“If everyone entitled to the card was taking it up the Department of Health would not have to do advertising telling people they are entitled to it.
“People aren’t as eager to take up the card, especially an otherwise healthy population that might only come to the doctor once in a blue moon. They don’t mind paying the odd consultation fee. But if you have a young child, it’s different, as you can be constantly going to the doctor.”
This also applies to the older population. However, outside these examples, “you’re talking about a population who, for the most part, don’t see doctors that often anyway. That’s my own personal observation.”
He outlined that GPs are informing patients about the visit card change but, for whatever reasons, they are not applying.
Dr Shanahan acknowledged that the HSE and Department had tried to make the process more straightforward. However, he noted: “There’s still a bit involved in it.”
Dr Shanahan, and other GPs, have remarked that workload at practices everywhere remain onerous despite the lack of a surge in footfall since GPVC changes.
None of the GPs who spoke to this newspaper believed that access to a GP was a factor hindering uptake of cards.
The HSE, where patients entitled to a GPVC cannot secure a GP, assigns a patient to their practice of choice where possible.
Dr Denis McCauley, President of the IMO, does not believe that access is acting as a barrier to take up. He argued that GPs do their best to accommodate patients where possible.
“Around 95 per cent of practices that have closed their lists is to public and private and private patients,” Dr McCauley told MI.
“When we closed our list, it was to everybody. We are trying our hardest to let people in. Our list is limited. But anyone with an association to the practice is let in,” the Donegal GP said.
Market research
The HSE’s spokesperson said it conducted market research to understand what may motivate or inhibit people to apply for a GP visit card.
“The most common barrier was eligibility perception. More than half of people felt that they wouldn’t qualify for a GP visit card based on their income, assuming that they earned too much to be eligible.
“Messages aimed at explaining who is eligible based on sample income and expenses were seen as helpful in motivating them to apply. [The] HSE has recently developed a social media campaign on multiple platforms including Facebook, Instagram, X, and Tiktok, that aims to address this barrier.
“The Department of Health also ran a mass media campaign promoting GP visit cards on radio, digital, and outdoor.”
This year, the PCRS also surveyed those who engaged with the means-assessed GPVC system. Some 3,840 clients responded to the survey. “PCRS are collating the feedback from responses with a view to identifying and actioning improvements,” the spokesperson said.
Multi-annual
The IMO is in favour of universal GP care, free at the point of access.
“Moving to such a system, however, must be done in a planned, resourced, agreed, and multi-annual manner. It is essential that the capacity is delivered prior to expanding free GP Care further,” a spokesperson for the IMO said.
All of those who receive a GPVC are entitled to care under the GP chronic disease management (CDM) programme, the spokesperson highlighted.
“While national policy is focused on expanding access to GP care through doctor visit cards, there is a need to further improve and enhance the range of services provided in general practice.
“The chronic disease management programme, negotiated with the IMO in 2019, has reached its target of 430,000 patients… and a further 100,000 opportunistic case findings were made. Open to all GMS/DVC cardholders with specified chronic conditions, the IMO is seeking that CDM programmes would be extended on a universal basis to all patients with specified chronic conditions over 18 years of age.”
The Organisation highlighted the challenges facing GPs, many of whom are unable to take reasonable leave from their practices, as they tend to an older,
sicker population.
The spokesperson said: “As the population ages, it has greater health needs and this places greater capacity demands on the health system. At the same time, the number of GMS contract holders in 2014 was 2,403 and now that number is 2,542. An increase of just 139 GPs or 5.7 per cent. At the same time, patient demand has increased at a much greater rate.”
Dr McCauley said he raised the issue of poor uptake with Minister Donnelly at the IMO AGM last April.
“The HSE and the Minister came to us asking our opinion of this and the feedback we gave from the patients is that they don’t like the application process. The amount of information being asked was an inhibition,” Dr McCauley explained.
At that time, he said, take up was reported to be very low.
“I’ve been told it’s less than one-in-10. Earlier this year, there were at least 500,000 potential GP visit cards available and there was around 45,000 take-up. It was tiny,” he said.
Another potential factor is that some patients may feel embarrassed about having a GPVC, Dr McCauley said.
“It’s okay to have a GP visit card,” he underlined. “It isn’t stigmatising to have a GP visit card. I would say, as President of the IMO, if I was entitled to a GP visit card I would take one.”
He stressed the importance of GPVCs for those who may otherwise struggle financially to pay to see a GP.
“I want people at the border of a financial barrier to get cards because these are people that genuinely need these cards. An income limit system is the fairest system available,” he argued.
Although the principle of free GP care is one the IMO advocates, Dr McCauley said further capacity is required before greater access can be granted.
Strategic review
Capacity and workload within general practice remain extremely challenging, according to Dr McCauley.
A Department of Health spokesperson said that issues relating to medical and GP visit cards will be kept under review in 2024 and 2025.
“The Department will continue to review the existing eligibility framework to clearly assess what is working well and to inform policy proposals to enhance eligibility and access to services based on robust evidence.”
The spokesperson added that the strategic review of general practice, which began last year, is continuing.
“The review is being undertaken in the context of Sláintecare and is examining areas that may affect general practice including GP training, GP capacity, out-of-hours services reform, the e-health agenda, and the financial support model for general practice.
“Following completion of the review, scheduled for this year, a report will be presented to the Minister for Health outlining the findings of the review and setting out recommended actions for a more sustainable model of general practice.”
They added that “a new public information campaign is currently underway to encourage uptake of the GP visit card”.
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