Dr. Mark Murphy:

I will try to address the contributions as briefly I can. I am sure Dr. Noonan will develop and better some of my points. Regarding integration, like all workers, we work based upon a contract, which must be operationalised by a union. I am afraid to say that, but it is the way the world works. If we are to take on work and integrate and communicate with our hospital colleagues in an improved way, which we should, that must be operationalised with unions. That comes first but it must happen.

To respond to Deputy O'Connell, the multiple pharmacists I deal with day to day basis would be appalled if I did not say that they are absolutely the core trusted people in the primary care team. I talk to them every day. I apologise for that omission absolutely. Regarding multi-morbidity, in the NHS there is a deprivation weighting in the capitation payment and a multi-morbidity weighting. I could talk at length about the IT aspects that could be improved. Our capitation can be weighted based on multi-morbidity. It is done over there. We can do it here.

Regarding Deputy Harty's second point about inverse incentives, the inverse care law, as he knows, is alive and well. Care is not where it should be, as he said last week.

There is no perverse incentive in this regard. We want GPs working with our deprived communities and multi-morbid populations, and I do not see any perverse incentive.

Deputy O'Connell's final point pertained to mental health and the €5,000. I will expand on this matter. This is a typical reality. We need universal health care. At present, 40% of the population receives free GP care. Those people get good quality care. They have free access to primary care and counselling in primary care, which Dr. Osborne may speak about, but there is a nine-month waiting list. This means that 60% of the population must pay to see me. Someone who is severely depressed must come back frequently and pay for 12 or 14 sessions of cognitive behavioural therapy. This is not uncommon. Both of these scenarios are completely untenable and involve Irish patients making catastrophic out-of-pocket payments, which is a technical academic term, which patients in other areas of Europe do not have to make. These are the issues over which we lose sleep. It is very difficult.

On the corporatisation element to which to Deputy Harty referred, we must operate on evidence. We know publicly-funded general practice is the cheapest and most efficient way to manage care. There are for-profit insurance companies and large corporate pharmacy chains trying to get into the market, and this is how they see it. They see this as a market, and it must be stated on the record they see persons as consumers and they are trying to extract money from them. The best way to manage health care is to enable GPs to manage illnesses and refer people to publicly-funded secondary care if possible.

It is very substandard. The typical reality is people come to our practice with fancy medicals from corporatised health care environments, and it is left to us to put the pieces together, as Deputy Harty knows.