Dr. Brendan O'Shea:

I thank members for listening to us. We sense their interest and knowledge. They have become somewhat expert in the inverse care law, so I will not restate it. However, there is a corollary. Dr. Julian Tudor Hart, a Welsh GP, stated that the impact of the inverse care law is most destructive where health care was commercialised, that is, where commercial influences are allowed to operate in the economy. In certain respects, we are seeing that here in terms of the corporatisation of general practice, cherry-picking and rationing that happens in those kinds of health care systems.

The Chairman has asked me to wind down, so I will. It can be done, and we are sending the committee a copy of this. It is evidence from the US, which we have not looked on as a leading model in primary care but which has generated evidence in the past ten years. It is actually inspiring stuff and we would regard it as required reading for members.

We have done a quixotic thing, in that we asked the patient what he or she thought. This is a study of 600 patients with complex comorbidities. The data were gathered in community pharmacies by the Adelaide Health Foundation. When we asked the patients where they would like their chronic disease management to be done, they overwhelmingly stated that they would like it to be done in a GP-led service in the community. They did not rate as highly a consultant-led service in the hospital or in the community. They wanted it to be done by GPs and, to some extent, practice nurses. There is a great deal of useful data. Some of it is hurtful in terms of the inequalities that come across. I wish to refer to one sad paper by Professor Ivan Perry et althat examines the extent to which we carry out lower extremity amputations on our diabetic patients. It is a key marker of how good we are at chronic disease management. The paper notes that, between 2005 and 2009 in the UK, the number of such amputations per 100,000 diabetics decreased from 275 to 250. That was with an older population. In Ireland, it increased from 144 to 175. We are failing at chronic disease management in a bad way. There are other papers of which the committee is aware. We were asked about Dr. Margaret O'Riordan's paper, so I will not reference it, and I have here is Dr. Liam Glynn's paper on complex comorbidities.

There have been some wins. Carlow-Kilkenny has been inspiring. There was an engagement approximately a year and a half ago when we communicated to the Minister of the day the need to move ahead on chronic disease management, and there was a small piece of progress as a result. A cycle of care for diabetic care was introduced through the appropriate channel. It is a small start, so may we please accelerate it? Chronic disease management in patients attending a general practice setting amounts to 9.2 visits per year and most of the care delivered by GPs. Of those 9.2 consultations, only 1.7 were delivered by the practice nurse. If the Government delivers a new contract that merely allows us to turn that around, we will begin to imitate systems that are more effective and less expensive. What we are doing has a shocking cost in terms of more complex chronic diseases being diagnosed lately and managed far less efficiently.

A number of lovely studies have been done in practice that illustrate what GPs can do, that we can intervene in breast-feeding rates in antenatal care and that we can check the weight of children and parents are welcoming of it. They have been done by registrars, many of whom have left the system. We wonder whether they will ever return. We will leave the committee with a copy of these.

I thank members for listening to us. I hope that we have not spilled over too much into their time. We wish them the very best success because we are all depending on one another in this regard. We are going to turn into the people with complex comorbidities. We sincerely hope that the system can become kinder to us when our time comes.