Dr. Martin Daly:

I thank the committee for affording this opportunity to the Irish Medical Organisation, IMO, to set out our views on the issue of maintaining effective services and presence of GP services in rural communities. As the committee is aware, the IMO is both the representative body and the trade union for the medical profession in this country. The experiences of the medical profession in Ireland and rural GPs in particular have informed our submission to the committee. The written submission made by our organisation to this committee provides recommendations on a wide range of actions which, if implemented, could help to maintain an effective service which general practice already provides in rural areas.

In these opening remarks, I would like to focus on particular issues which have affected GP recruitment and retention in remote and rural communities in recent years. I myself am a rural GP practicing in Ballygar, County Galway. In order to understand the current problems in rural general practice, it is essential to first understand some of the background to these issues. GPs are paid on a capitation basis for the medical card patients and doctor-only visit card patients. Capitation is paid monthly and ranges from €43 per annum for a child between the ages of six and 16 , and €270 per annum for a patient aged 70 or over. For a seven-year old male GMS patient, for example, a GP is now paid €3.58 per month. This capitation fee is paid regardless of the number of visits made by the patients. The same fee is paid whether the patient visits once or twenty times a year.

In 2008, Ireland had a functioning general practice system by and large, in which GP posts became vacant through retirement or resignation from the GMS system. There were in most cases a number of suitable applicants applying for those posts. In addition, there was a greater capacity at that time and the practice could afford additional help from assistant GPs and sessional GPs to provide a greater breadth and depth of services in their practices. I am an IMO representative on the GMS interview boards in the western region and I have seen first hand the drop off in the number of suitably-qualified candidates applying for positions. In some cases, GMS lists which were advertised and had no suitable applicants have been dispersed amongst GPs in the area. This is where the patients and the retiring doctors lists are essentially divided among the remaining GPs in the region. This leads to a reduction in the number of GPs and often means that patients have to travel further to see their GP. It also increases the workload for the remaining GPs in an area, especially in the context of the provision of out-of-hours services.

In other cases, patient lists were merged. This occurs when GMS lists, which once would have attracted a number of candidates, are no longer viable as stand-alone lists. This problem has been exacerbated by additional and onerous extra-contractual obligations being surreptitiously inserted by the HSE in job descriptions, thereby making them more unattractive to new candidates. For example, where once there may have been two lists of 600 patients serviced locally by two separate GPs, such lists may now be merged to form one list of 1200 patients and serviced by one GP, resulting in less capacity and less choice for the patients in that area. In the official HSE statistics, these posts are no longer considered vacant or unfilled, as patients have been attached to a GP. Thus the official statistics on GP vacancies understate the scale of the problem.

What has gone wrong since 2008? Simply put, GMS rates have decreased significantly, while at the same time workloads have increased dramatically. There is now a real problem with capacity in general practice. In 2008, 1.4 million patients had a GMS or doctor visit card. This has increased to more than 2 million people. With an increase in free-at-the-point-of-access GP services comes an increase in patient visitation rates and workload and a diminution to provide and maintain greater breadth and depth of service in practice.

At the same time, GPs have had their fees cut by 38% in 2008. We recognise that those cuts applied to many people who were paid from the public purse. For the public service, FEMPI cuts were made to incomes. For GPs as contractors, these cuts have been made on turnover. This is a crucial point because costs have remained fixed and the effect was to have a doubling-down effect on GP incomes. It was a crude and, in our view, an unfair methodology with which to make those cuts. Where GPs have been fortunate enough to have some private practice, they have subsidised their GMS or medical card income. Unfortunately, in most rural areas, there is a reduced potential for GPs to subsidise their public service with private practice.

GPs who have been in practice for many years find they have no succession model to enable them to pass on their practices, resulting in reduced potential for investment in practices. If someone cannot know that his or her practice will be taken over, he or she has no way of realising the value of investments he or she has made in buildings, services and instrumentation. It also has a major effect in that a GP has to make redundancy payments when he or she retires if no succession arrangements have been made. Many young GPs look at practices and, having done the mathematics, see that they are unviable. They have options elsewhere, within this jurisdiction and overseas, and are emigrating in increasing numbers.

To exacerbate matters further, there is an ageing population; in Ireland 540,000 people, or 12% of the total population, are aged 65 years and over. This figure is set to rise to 1.4 million, or 22 % of the total population, by 2041. While changes for this group are striking, those projected for the group aged 80 years and over are even more dramatic. In the same 30-year period the number of people aged 80 years and over is projected to rise from 130,600 to 458,000, an increase of 250%. With increased age come increased and more complex health needs. It is essential that we build capacity in general practice to address increasing demand and provide the most appropriate and efficiently-delivered services in communities. One method to increase capacity would be the introduction of an assistant GP subsidy, similar to the current practice nurse and secretary subsidies, to fund GPs to take on assistant GPs and increase capacity to provide services in their practices while allowing for a seamless succession within the practice. This would also allow GPs who do not wish at this time to have a GMS list to remain working in the system while gaining valuable experience.

In order to attract and retain GPs in rural areas, as well as in many urban areas, it is vital that the cuts n the past eight years under the FEMPI legislation begin to be unwound and that a new GP contract, to replace the outdated GMS contract, be negotiated. GP contracts in the NHS have been renegotiated on at least four occasions since 1989 and the contract here is essentially the same as that provided for in 1972. Some progress has been made with the recent agreement between the IMO and the HSE on the new support framework for rural practice, which we acknowledge. Approximately 250 GP practices will benefit from this support, an increase of 100 on the number under the previous rural practice allowance scheme. There are many GPs who are considered to be practising in rural areas but who may still not qualify for the allowance.

Prior to 2010, a patient capitation fee was paid according to age, gender and distance from the GP's surgery; the further the distance from the surgery the higher the capitation payment, subject to an upper limit of ten miles. In 2010 distance coding was removed as a factor in making capitation payments, leading to a disproportionate effect on rural practices as, by their very nature, patient lists in rural areas tend to be more geographically dispersed. Distance coding was also removed as a factor in making payments for house calls. A GP is now paid the same amount for making an out-of-hours call - between 6 p.m. and 8 a.m. - whether the patient is 15 miles away, next door to the GP surgery or has the service provided at the surgery . The fee is €41, but for in-hours house calls there is no additional fee. Rural GPs relied on distance coding for some compensation for, and recognition of, house calls made during surgery hours. House calls are predominantly made in rural areas, but while they are based on the professional judgment of the GP, in practice they serve old people living alone in remote rural areas and nursing homes in rural areas who do not have decent access to medical services in the community. This is because of faulty planning and it has been exacerbated by the dearth of public transport services in rural areas. In emergencies they are still necessary, but public policy has now created a disincentive to make such calls, leading to increased ambulance call-outs, the cost of which is far in excess of what was saved in removing distance coding. Aside from the pressing need for a GP contract, one measure that would help to maintain GP services in rural Ireland is the unwinding of the FEMPI legislation as it applies to GPs. This process has begun for public servants and it is only right that GPs, as contractors, should be entitled to the same process aimed at a phased, targeted unwinding of the cuts which have so badly affected general practice and rural general practice, in particular.