Dr. Martin Daly:

On behalf of the Irish Medical Organisation, we welcome the rural practice deal that was done. I recognise Mr. O'Dowd and his team, who were negotiating on the other side.

We want to understand how we got there. It was not as if the HSE or the Department led us through the door and said, "Come on, lads, we need to sort out the issue of rural general practice." It was sorted out because there was severe disenchantment among general practitioners, their patients and communities about the manner in which the HSE and the Department were dealing with it.

Deputy Éamon Ó Cuív pointed very clearly to one particular issue in Renvyle, on which I was in touch with him at the time as a Deputy for the area. The lesson was that the culture had nothing to do with the enhancement or maintenance of rural general practitioner services. In fact, in our view, it was the exact opposite. It was the undermining of general practice in many places in the west of which I was aware of. How could anyone suggest a GP operating alone in Renvyle, providing the only medical service from a small Connemara village on the edge of Clifden for a community on the western seaboard, should not be supported? How could anyone with common sense within the HSE or the Department not understand that in undermining that person one would never have a doctor in the area again? Not only would there not be a doctor in it again, there would also be a knock-on effect. There are two practices in Clifden in which there were six doctors, but they are now down to four because of cutbacks. A situation has been created where the service for the whole area has been reduced. The capacity of GPs in the area to provide a greater breadth and depth of services and attract new young GPs has been reduced. That is the culture. It is not simply about money to attract people to work in Ireland in general and rural areas in particular, it is also about the culture. If there is a culture of support, one will get people to buy in. However, the culture in Renvyle, in spite of all the political representations, as well as ours, was one of a closed shop and the attitude was "We do not care if he survives or not in Renvyle."

There was the undermining of rural general practice in the case of a number of general practices in the west that fed into that disenchantment. Extra contractual obligations were inserted into job descriptions for GP services in rural towns in the west. There is a GMS contract which has been in place since 1972, as amended in 1989, but additional onerous requirements were being added for candidates in applying for these jobs. For example, it was suggested a GP coming to a rural community such as Frenchpark, County Roscommon had to make an open-ended commitment to move to a primary care centre in Ballaghaderreen at an undesignated time in the future under undesignated terms and conditions. That GP was going to come to Frenchpark and invest in a practice and at some time to be determined by the HSE and the Department be asked to move to a primary care centre in Ballaghaderreen. What was to happen to the investment in Frenchpark? In fact, what would have happened was that Frenchpark would have been left without a service. Half of it would have been provided in Castlerea and other in Ballaghaderreen. Now, there is no practice. Why would a young GP move into such a service? In addition, no one discussed with the GPs in Ballaghaderreen that another doctor was coming and whether they would move into a primary care centre in spite of the two practices in Ballaghaderreen already having invested in their own premises. That is not a culture which encourages people to move into rural areas.

The same happened in Dunmore, County Galway, where the additional onerous contractual requirement to move to a primary care centre in Glenamaddy at some undetermined time in the future was to be inserted into the job description. The GP in Glenamaddy had not been consulted. It took three years to appoint a GP to Glenamaddy because it was a rural area and there was a big list. The same happened in Williamstown, County Galway. These are real examples and to suggest that, in some sense, the Department and the HSE had a culture of leading us through the door to resolve the rural general practice issue is inaccurate. It was done under duress and forced by the difficulty in getting people to move to rural areas, the disenchantment of GPs and their disengagement from service. For example, distance coding, of which very little is made by the HSE and the Department, psychologically, is a major issue in return for very little money. GPs in rural areas made house calls. That is the reality. I still make six or seven house calls a day in a remote rural area to elderly people living on their own and nursing homes which have been placed in rural areas with little infrastructure around them. The culture of making house calls, however, has been absolutely destroyed because GPs have asked themselves: "Why would I make one? Call an ambulance." The culture has changed and cannot be bought back, yet it costs a fortune to have an ambulance, two paramedics and an advanced emergency specialist ride to the home of an old person with a chest infection who might need additional home help and could be treated at home. Psychologically, distance coding is major and our information is that the primary care reimbursement service, PRCS, did not like it because it was far too much work. That is the reason it was targeted. It had nothing to do with the benefit to rural communities.

On primary care teams, things have been overly prescriptive. The primary care strategy was published in 2001, but 15 years later we still do not have comprehensive, functioning primary care teams nationally. Any suggestion to the contrary is simply about box-ticking. It has nothing to do with the reality on the ground. It prescribed the relationship between every member of the primary care team down to where they would meet. Pulling GPs out of their surgeries while 20 patients are sitting in a waiting room to discuss another GP's patients ten miles away is not a functioning primary care team and it is not working because there are not enough staff members on the ground. It pays lip service to primary care. There are not enough allied care and nursing professionals and home helps available.

On diagnostics, I beg to differ. In fairness, it was initially the case that after the closure of the emergency unit at Roscommon County Hospital, we had access to diagnostic services, including ultrasound and CT scan facilities. This is the modern era, but patients cannot access scanning. Plain X-ray facilities are not enough. Access to ultrasound, CT scan and MRI facilities should be available to public patients. However, public patients are putting their hands in their pockets and getting money from their relatives to have an MRI scan taken of the backs of their knees. That should not be happening. We received a two-line letter from Roscommon County Hospital which stated we would no longer have access for our patients to ultrasound or CT scans. There was no explanation or consultation; it was simply stated, "You do not have it." What are the options? A doctor sends his or her patients to the casualty department in an ambulance or to an out-patient appointment which will take six or nine months to arrange, even though it involves a simple procedure. The suggestion, in spite of these initiatives, that there is access to ultrasound and CT scans is simply not true. That is my experience as a working GP on the ground.