Dr. Ray Walley:

As there is an element of à la cartewe will all make a contribution. What I am going to say in regard to our engagement with the Minister is quite terse. Basically, we are in discussion with the Minister of State at the Department of Health, Deputy Alex White, and our agreed comment on it has been that we have had useful talks and that the process continues. I do not want to jeopardise that in any way, but the talks continue.
In regard to a preventative role, one area where general practitioners feel constrained is in providing preventative medicine. We have time-bombs in regard to the development of diabetes and obesity and other health care issues. Certainly, it is part of our training as hospital doctors coming through the system and going into general practice. General practice training in this country continues for four years and involves medicine and other areas of paediatrics, obstetrics and so on but the problem is that within the current contract we cannot use those skillsets. Pilots have been conducted in Ireland on, for example, diabetes shared care and these have been progressed considerably to the point where they are almost at contract level. The evidence with the pilots is that not only do we provide better care and better statistics in regard to mobility and mortality than the hospitals - that is not to dismiss what the hospitals do as they do not have the resources either - but there is no reason the majority of this work cannot be done in communities. General practitioners work in each community throughout the country and there is no reason people have to travel to a hospital for the majority of diabetic care.
Savings can be made in diabetic care. Given that renal dialysis costs €100,000 per year and that the most common cause of renal failure is diabetes, if one was to delay its progression by six months that is a saving of €50,000. The most common cause of blindness is also diabetes. The social benefit of reducing the progression of blindness is phenomenal, not to mention the monetary cost. Those are issues on which we wish to use our skillsets but there are many other areas where we could do that, such as in cardiovascular health, mental health and so on. As there is an explosion of elderly people coming down the line we want to be involved in dealing with stroke prevention, dementia prevention and so on which can be dealt with in general practice.
An issue mentioned was bottlenecks in access to diagnostics. Due to the withdrawal of resources, many general practitioners do not have access to 24 hour blood pressure machines. For example, in my local area - I refer to Beaumont Hospital - there is a four-month waiting time for that, which is extending. If a person was to purchase such a machine in private health care it will cost in the order of €180. Hypertension is very common and a risk factor for stroke, diabetes in conjunction with other illnesses, and dementia, therefore it is important that we have access to it.
On the issue of the shortage of general practitioners, recently the committee may have read that for the first time ever the number of general practice posts applied for in training was deficient in numbers. We have 157 training posts for general practitioners. These are four-year contracts.They are contracts where a person knows where he or she will be for the next four years. For the first time ever we have only 150 suitably trained applicants for those 157 posts. We are haemorrhaging young doctors. Not only are they leaving when they qualify, they are not even willing to stay to do their raining here because they are being sourced by locum agencies throughout the English speaking world to go to Australia, Canada and the UK. Of more concern is that for the first time we are losing middle-aged general practitioners. A couple of weeks ago 25 general practitioners left for Qatar. We are aware of that because there was a large group of individuals involved but three, four and five people in their mid-fifties are leaving for places such as Canada. The average age of a general practitioner here is 52 years.
We have got to ensure we retain our existing general practitioners, of whom there are 2,414. We need to retain the one in eight GPs, who is over 64 years of age because most of them want to work. However, they want to work without having to deal with all the difficulties in the system. The committee will have read of all the difficulties in the UK and there are similar difficulties here. There are difficulties with burn-out because of the workload implications. People are working 12-hour days. People are arriving at work before their staff and leaving after their staff. It is not an attractive job but it is a job we all love and do and we all want to work in our communities. Putting more training posts in place will not resolve the position. We need to ensure we can retain the existing general practitioners. This issue has been looked in the McCraith report into which the IMO has had an imput.
With regard to the GPs who are applying for the training posts, the most common reason given for not wishing to take up a GP training post here was the uncertainty for the future. The present generation travels easier, are more confident to travel, and are more likely to stay where they go. The majority are trained by the time they arrive. They get into the workforce early, find their feet, have a family and after four or five years they want to get citizenship for their children. After they remain for seven or eight years they are less likely to come back. I know that as I was one of those individuals who emigrated in 1990. The difference was I emigrated for my training. Nowadays, the majority who emigrate are trained and are less likely to come back. That is a very expensive loss of a resource besides the fact that one would expect the community to stay and look after its own community.
On the issue of off-loading workload, a high proportion of us work in teams with practice nurses and secretaries. Secretaries do the work of secretaries and nurses do the work of nurses while GPs do the work of GPs. We have always worked in teams. In recent years, the HSE has realised that primary care teams exist. We have always dealt with them and we have all embraced changed. All our CME is done outside of our working hours, between 5 p.m. and 9 a.m. We are engaged in education all the time. General practice here is of a high quality and we want to continue to prove that. We want to work in teams within our general practice and within primary care but both must be funded. In these systems of work, 10% goes to general practice and 10% goes to primary care teams. Anything outside the hospital and outside the GP surgery is primary care. All of it, general practice and primary care, adds up to community care. There is a need to resource the public health nurses, social workers, occupational therapists and speech therapists because if they are not available they come back to the general practice. We can only do our own job.
In regard to continuity of care, I was a founding chairperson of the D-Doc out of hours service. I brought my skillset from the UK where I was one of the individuals who set up Brightdoc in Brighton. The majority of shifts in D-Doc, which is the same as other co-operatives throughout the country, are done by general practitioners where, through economies of scale, we cover a population of 0.5 million people. We have a visiting service for those who cannot come to the surgery and as a result, the majority of the care is provided by GPs local to the community. Certainly, we do not have the manpower to do all those hours. We no longer want people working 24 hours. If one is working those hours, one is more likely to make a mistake. Those reports are faxed back to the individual GP who looks at it. I had a lady one night recently who had a problem. The GP who was seeing it thought it was acute but to me, who knows the lady, I was able to engage with somebody else to say this is a repeated problem which we need to deal with elsewhere. In that way the person concerned got more appropriate care. All of that amounts to continuity of care with appropriate use of IT technology. That is not to say one cannot improve.
In regard to the 97% satisfaction rate, I am pleased to say that comes from a State organisation, the Medical Council. It is similar to the previous study which showed a 93% satisfaction rate the previous year.

When the HSE conducts its studies, they are also over 80%. The last one they did was three or four years ago, and it was in the order of 84%. They are coming from State organisations that we do not influence.