The struggle to regulate Gesy goes on – but the health system is like a moving target, defying any attempt to control it.

The latest initiative is the ‘urgent referral’ system announced by the Health Insurance Organisation (HIO) a couple of weeks ago.  

This was long overdue. As is well-known, the arrival of free healthcare – plus the fact that personal doctors are far too lax about referring patients to specialists – has led to an explosion in patients seeking treatment, to the extent that actual emergencies often face a long wait before being seen.

The new system establishes two categories for referrals, ‘urgent’ and ‘normal’, and provides that the former must be seen by a specialist within 10 days of the referral being issued.  

This is obviously welcome – but will it make any difference? The trouble is that well-meaning reforms can only work in a culture of honesty and transparency, whereas the reality is often quite different.

Whether a referral is urgent or normal will be at the discretion of the patient’s general practitioner, said HIO director Andreas Papakonstantinou – meaning, in effect, that GPs are presented with a two-tier system.

It goes without saying that most patients will plead to be labelled ‘urgent’, both to get an early appointment and because people tend to be paranoid about their health.

What are GPs likely to do? Let’s not be cynical and assume they’ll play favourites, or help their friends, or even accept money – though of course all those things are possible.

Even without all that, they’re likely to play it safe and categorise cases as ‘urgent’ whenever possible. After all, who wants to be the one who dismissed a patient’s symptoms as non-urgent, only for the patient to die as a result?    

There are guidelines for doctors to follow, of course – but guidelines only go so far. A GP can always claim that, in their judgment, the case was potentially urgent.

The only one who can say for sure is the specialist to whom it’s referred – and if, for instance, specialists had to note every time when a case was miscategorised, it’d be easier to see who was abusing the system. But why should a specialist land a fellow doctor in hot water?

Coincidentally, news came this week of a gynaecologist being fined €15,000 by the HIO for deliberately misclassifying routine C-sections as emergency procedures, in order to claim higher payments.

It appears this particular doctor got greedy, scheduling so many ‘emergencies’ that it activated the Gesy software designed to spot irregularities. But it’s surely the case that most doctors declare an emergency when they think they can get away with it – just as doctors now advise patients to have many more check-ups and MRIs than in the past, even when not strictly necessary.

We’re certainly not arguing against the existence of a national health system, which has indeed allowed healthcare to be accessed by people who couldn’t afford it in the past.

But it’s also true that, in a free market, incentives arise rationally because they’re decided by the market – whereas, in a planned system, incentives are imposed by the system, and lead (some) people to behave in irrational ways in order to game the system.

Hopefully, enough safeguards are in place for this ‘urgent referral’ wheeze to avoid unintended consequences.