Dr. Mark Murphy:

I will contextualise the role of the general practitioner in modern Ireland. A typical GP on the islands and in the towns and cities of Ireland consults directly with approximately 40 patients daily and makes clinical decisions on a further 20 to 40 patients through telephone consulting, repeat prescriptions and actions arising from medical correspondence. We have a very busy day and manage a wide range of acute and chronic conditions. GPs provide comprehensive care and manage every single complaint that comes through the door. We provide for continuity of care and get to know families and patients over time, which is probably why general practice is so effective. We co-ordinate the care needs of patients through a very fragmented and complicated system and are the first point of contact. In addition, we gate-keep entry to secondary care.

Over nine out of ten of the presentations included in the submission to members are effectively managed by us without onward referral in the health care system, which makes it very effective. Strong evidence supports investment in general practice and primary care services. Adding one GP per 10,000 population reduces mortality, which is not necessarily true in the case of a secondary care consultant. It will reduce the number of emergency department visits, inpatient admissions and outpatient visits and improve the level of health care inequalities.

The GP has hit a roadblock and in the last decade, particularly since 2007, the impact of FEMPI legislation cuts on the PCRS-eligible population, together with concurrent reductions in private income, have seen a fundamental destabilisation of general practice in Ireland. Regrettably, there was a tipping point during the winter of 2015-16. The prioritisation of acute, urgent presentations in general practice above chronic diseases has resulted in a dangerously stressed workforce in general practice which will be unable to consistently deliver excellence in care unless resourcing shortfalls are addressed urgently.

I will outline seven solutions to fix general practice and enable us to manage chronic diseases. Chronic disease management refers to cardio-metabolic conditions, arrhythmias, heart failure, respiratory conditions such as chronic obstructive pulmonary disease and pain conditions such as osteoarthritis, as well as mental health conditions, which are managed by us. The current model of chronic disease management, CDM, in Irish health system is expensive, inefficient and lacks patient-centredness. It has historically been based on an underfunded single-disease model, with poorly defined management between primary and secondary care services. Effective chronic illness management in general practice reduces overall health care costs, improves outcomes for patients and reduces secondary care utilisation. As we get to do what we are trained to do, it improves our working environment and delivers more care services in the community. For example, the Heartwatch programme, led by GPs and practice nurses, dealt with the secondary prevention of heart disease. The death rate was 5% in Heartwatch patients, as against 14% for those not in the programme. It is a cost-effective solution in chronic disease management. It is unjustifiable and inexplicable that it was not rolled out nationwide. Patients have died because a cost-effective GP-led chronic disease management programme was not rolled out.

We recommend the urgent contractual provision of GP-led chronic disease management in communities, fully encompassing the care needs of the complex individual with comorbidities. GP-led chronic disease management will enable hospitals to do what they do best. General practice needs an enhanced role in integrated care programmes, as well as clinical care programmes

Access to diagnostics is also crucial in chronic disease management. We do not have reasonable or effective access to diagnostics, especially radiological tests, CT scans, MRIs and ultrasounds. Some GPS have no access to them. We are also talking about endoscopic and cardiac investigations such as an echocardiograph or a BNP blood test. The end result is that patients end up on an outpatient waiting list or a trolley in an emergency department. It is ludicrous. Providing GPs with access to diagnostics enables patient management in the community. Diagnostic facilities should be considered to be separate from hospitals. We recommend a uniform national standard waiting time for key investigations based on reasonable international standards.

Consultation rates are rising with chronic diseases and an ageing population. The under-sixes and other cohorts have free access to GP care; therefore, we need to increase capacity in general practice and primary care services. We need more GPs and a new contract. We need to train more GPs, but we are still awaiting the service level agreement to be signed with the HSE. Once that is done, we can train more GPs, but it does not make sense to train more only for them to emigrate. All my friends are in Australia and Canada. We have to focus on recruitment and retention strategies, chief among them being a new contract to improve our working conditions. We need to focus on certain groups, particularly rural practices and practices in the deprived inner city. We also need to increase the numbers of GPs and of practice nurses to deal with chronic disease.

We do not use IT efficiently. We utilise electronic health records which hospitals have, but the two systems do not communicate. Therefore, we need to expedite introduction of the individualised patient identifier. Having a central summary record is one suggestion. We can now e-refer patients to consultants. That has helped, although there has been a slow uptake in the past six months for a few reasons. We sometimes want to make an informal, unstructured query to a consultant through health mail, but that system has not yet taken off. We need to utilise routinely collected data as we do not know what is happening. Members of the Oireachtas want to know what is happening, too, and data help to bring accountability, quality and safety. Therefore, we need to resource these structures.

On the question of capacity in primary care services, we need to expand the number of primary care professionals, including psychologists, occupational therapists and physiotherapists. We need to resource public health nurses, carers and assistants because that leads to keeping elderly citizens at home for longer.

On community supports, GPs have first-hand knowledge that senior citizens would prefer additional supports in the community setting to enable them to remain at home or in adapted accommodation for longer.

Home care packages are essential to the provision of adequate services to elderly patients, providing autonomy, dignity and the ability to live where they want. Primary care teams are a priority for certain patient groups, and it is essential that primary care team meetings take place. We are well disposed to primary care teams. However, only a minority of GPs report positively on their experience. We can elucidate on that later.

On universal primary care, there is no doubt that we are an outlier. Most countries have removed cost barriers to general practice and primary care services, either through free access or subsidised payments. We support increasing access to general practice and primary care, but that is contingent on manpower, IT and built infrastructure capacity. That can only transpire if an adequate number of GPs are trained and retained in the system through a new GP contract, and expanding access through means testing is the fairest mechanism.

We can also prevent chronic diseases as GPs. A Government-wide approach on Healthy Ireland is needed to tackle obesity, sedentary lifestyle, smoking, problem alcohol use and stress. GPs, practice nurses and primary care professionals can make brief interventions to tackle effectively those lifestyle issues. That can reduce mortality, morbidity and costs, but we need to have the time and capacity to do that.

Finally, on general practice, we spend about 3% of our public health budget in general practice. The members heard from Professor Allyson Pollock this morning that the United Kingdom spends 11%. We recommend resourcing Irish general practice in line with other countries.

I will make three brief points about accessing secondary care that are pertinent to chronic disease management. To give a typical experience as a GP, one patient will wait two years to get her hip replacement. The next patient will wait two weeks, and on it goes for the 40 patients seen throughout the day. Only those 5% to 10% of patients need referral. That is deplorable.

The Irish College of General Practitioners, ICGP, supports the creation of a single-tier secondary care system, underpinned by principles of solidarity, equity, fairness and efficiency. We recommend that an all-party task force works with key health care stakeholders to consider the funding options that can deliver a single-tier system.

On emergency department overcrowding, chronic conditions become acutely uncontrolled because we are not looking after the patients appropriately. Those patients end up in the emergency department and are then admitted on trolleys. We are part of the solution. GP-led chronic disease management, more step-down facilities, enhanced social care in the community, enhanced GP co-operative roles, and the development of primary palliative care packages will help.

We would like to alert the committee to the hazards of an increasingly fragmented, "corporatised", "commoditised" health care system. For-profit corporations are targeting citizens and incentivising them to get investigations that might not be evidence based. That destabilises the health care system and chronic disease management. Effective public general practice and primary care is a proven way to add cohesion and continuity to a system which patients frequently experience as very frustrating.

In summary, a new GP contract with built in continual periodic review is essential to permit GP-led chronic disease management and build capacity. The new contract must embrace the needs of patients with multi-morbidity, that is, multiple chronic illnesses. It is essential to consolidate and build the numbers of GPs and practice nurses. I thank the members for listening.