Dr. Peadar Gilligan:

If I might, I might answer on a few of the issues. It is very appropriate that the committee's emphasis is on primary care and general practice because that is where the vast majority of health care interactions happen in this country on a daily basis. The issue of salaried GPs has been raised a number of times. It strikes me that we might not quite realise the asset we have in the current model of general practice. The independent practitioner is strategically responsible for his or her practice, manages his or her practice with the help of his or her practice manager, provides services, and knows his or her patients incredibly well. Because GPs know their patients extremely well, they tend to have quite low referral rates to the hospital system. Before we move away from a model that provides a terrific level of care, we must be conscious of the value that is already there.

Deputy Harty suggested there had not been a change in work practices in hospital medicine in Ireland in 40 years. While I have not been in hospital practice for quite 40 years, albeit there are days when I feel it has been 80, I assure the Deputy that it has changed hugely. To give one example, a patient with stroke coming to hospital ten years ago was managed largely in a palliative manner. Now, within three and a half hours of onset of symptoms, we are in a position to potentially thrombolise and reverse the effects of that stroke. Heart attack management has hugely changed. Historically, it was aspirin and oxygen, but we now treat that patient with a ST-elevation myocardial infarction to the cath lab within 90 minutes of arrival at hospital. We decrease the amount of heart tissue lost as a result of the heart attack. Those are just two examples across many, many specialties. As such, there has been absolute change in the hospital system and in the way we deliver care based on the evidence and what is best for patient care. The frustration for us as hospital doctors is that we know what we can do, but do not have the resources in place to do it. We do not have the staffing or capacity in place and sometimes we do not actually have the equipment we need to provide the care.

There was a specific question around the Carlow-Kilkenny model. In essence, the acute medical admission model and an interface with primary care and general practice has a role, but the Carlow-Kilkenny situation is really quite different. In the hospital where I work, if we had the number of nursing home beds available to us as per the demographic of our population that Kilkenny has, we would not have the problem we do with overcrowding. At any given time, 20% of our bed base is occupied by patients who would be better cared for, having undergone and completed their acute care, in a nursing home setting. However, we do not have those available to us. As such, it is not a model that can be rolled out across the country. The other thing to be cognisant of with regard to acute medical admission units is that unless they represent a real increase in capacity within the hospital and unless they represent an increase in staffing in the hospital to address the needs of the acutely admitted patient, they tend not to work. That can be seen nationally where acute medical units are failing because they do not have the resources they need. They do not have the bed base and do not have the ability to move the patient through the acute medical admission unit onto the ward because there is no ward available.

I was asked by Deputy Browne about allied health professionals and prescribing. There is a doctor's role and doctors perform it extremely well. There are also incredibly important roles in nursing, occupational therapy, physiotherapy and the social work departments of our hospitals and it is incredibly important that we identify the importance of those roles and support the people in them. We do not want and we do not need everyone doing the doctor's job. In fact, some of the time, what we need is for doctors not to have to do jobs which are not appropriate to that role so that they can get on and do the doctoring role. That is a model we need to look at but as things stand, we have prescribing rights for groups who go through a particular programme. For example, we have advanced nurse practitioners with prescribing rights throughout the country.

On the retention of consultants and the pay rate Deputy Kelleher mentioned, the last time we had a negotiated contract in Ireland was 2008. At that time, a pay structure was put in place, but it has never been honoured as I have identified for the committee. We have a real problem with regard to that. Not only has it not been honoured, it has been serially cut and then, dramatically, a further 30% cut was superimposed on the earlier cuts. We have a situation where hospital doctors do not actually feel their contract will be honoured by the employer side and that must be addressed. The Deputy is absolute right. The current pay rate and the concept that someone takes on a consultant role and does the same job as the person beside him or her but gets paid significantly less because of the time of his or her appointment is a huge barrier to recruitment and retention in the system currently.