Dr. Ray Walley:

It is with one's general practitioner.
We have a capacity problem because, for example, there are next to no locum general practitioners. Not only are the general practitioners who are trained moving on, but they are going to more attractive areas, such as the United Kingdom, Australia and Canada, and as a result we have lost the spare capacity in general practice. It has become an unattractive job because of a withdrawal of resources. As I stated, we are on 2.3% of the State's spend whereas the equivalent is 9% in the United Kingdom, 10% in Holland and 10% in Australia.
In regard to premises, many general practitioners over the years have invested in premises, many of which are high quality and fit for purpose. We agree that one needs to invest in premises where the need is there, but we want to scotch this view that we can do cardiac surgery, appendicectomies and all of those procedures that patients still need to go to hospital for. We can only provide general practice care. One will still have patients attending in casualty. A recent study in the British Medical Journalwithin the past week looked at the appropriateness of referral to casualty and the accident and emergency physicians who would like to be saying they are getting the wrong patients presented in casualty. However, it was found that the appropriate patients are being referred to casualty. I would say in the majority of cases that is so in Ireland as well, but the problem is, because general practice is starting to fray at the edges, many of the issues that should be going to casualty could be dealt with in general practices where we had the resources. That is something that we can improve on.
The majority of premises are fit for purpose. Where investment is needed it should occur in conjunction with talking to the local general practitioner to ascertain whether he or she has the ability to invest or whatever. They are the practitioners based in their own community.
In regard to drug savings, much of the pricing of medicines is not in our control. It is dealt with between the pharmacy lobby, be it the pharmaceutical companies and the pharmacists, and the Department of Health. We see, as part of chronic care, that one can have integrated heath care models whereby one can ensure that there is more appropriate prescribing, but that is all part of chronic care regimes. For example, one has this in the United Kingdom. Moneys have been invested back into general practice in regard to savings where there is a recognition - this is something recognised by the troika - that there are incentives to ensure that general practitioners are willing to meet the workload. As was stated earlier, we only have a ten minute consultation and at times that is reducing, and there is an insatiable appetite for health care. We can provide so much in a consultation but we must ensure that we prioritise what is most appropriate at the time and within our resources.
In regard to mental health, there is a pilot in the United Kingdom in regard to general practice being a more engaged area of mental health. It is something that we are not averse to. All of those prescriptions are still coming from the general practitioner and much of the reviews, physically, are coming from the general practitioner, but what we would like is a more integrated chronic care model to ensure that we can improve on that. Whatever we are doing, we can do better but we need more resources for it. I will ask Dr. Duffy to come in here.