Alan Kelly (Tipperary, Labour) | Oireachtas source

I welcome the witnesses. I apologise for being late. Unfortunately I am on two committees that sit at the same time on Thursday mornings, so I have to jump between the Committee of Public Accounts and the Joint Committee on Health. Like Deputies O'Reilly and Kelleher, I too am a member of the Committee on the Future of Healthcare, which is devising a plan for the next ten years. Politics has failed health in the past 30 years. There has been constant change, constant movement on strategy, geographical imbalances and not taking account of the demographics, as well as a range of issues. We need a timely and comprehensive plan for health.

I often find that the internal politics of health could actually give professional politics a run for its money. In fact in many cases I think it is worse, which is part of the problem. The internal politics of health are a significant issue. Somebody needs to bite the bullet and say it out straight. In the future of health care process, there is agreement - more or less - that there will be a period of transition and transitional funding will be required. Decisions are being made on a range of issues which cross over to the direction of the recommendations.

Obviously, the whole area of the GP contract is intrinsic to it. One of the best presentations given to the Committee on the Future of Healthcare was from a number of the hospital groups. One group CEO, Colette Cowan, said that in order to alleviate the issue she had in her hospital in Limerick the best thing to do would be to take away a whole pile of her budget and actually put it out into the community and primary care. That is the sort of thinking we need from everybody; someone who wants to give away a large amount of their own budget and someone who is willing to actually change the way they do things. The way in which GP practices are currently orientated is not right or correct. There is not a comprehensiveness with regard to service provision, geography or anything else. This is partly the fault of politics and the fallout of health strategy. It is also partly the fault of the GPs. Nobody is immune. Politicians are at fault, health professionals are at fault, health strategy is at fault and GPs are at fault.

The future of health is like a big jigsaw that is going to have to be put together. It is going to take a comprehensive period of time and a lot of political leadership over the next number of years. It is also going to take leadership from the individual bodies. We all know that with regard to the next GP contract, there were issues with what was previously left in place for a ridiculous length of time around its inflexibility and the way in which it was structured. I have had numerous conversations with many members of the representatives' organisations on this, especially over the past year. We are facing into a crisis given the volume of GPs who are about to retire, the demographic changes and the fact that we are not creating enough training places. That is all obvious and it needs to be dealt with quickly. I reflected on what my colleague Deputy Billy Kelleher said earlier that it is absolutely bananas for negotiations for the GP contract to go on without all of the representative organisations in the room. It is nuts. It shows that we have not learned anything and that we are going down the same road again. An action of this committee - that I hope the members will support- is to write to the Minister for Health on foot of this and make a recommendation that the negotiations are to include everybody. Otherwise the negotiations will then have to be continually reassessed. It is going to go on for years, and we do not have years. I hope the Chairman will take this on board, please, as one recommendation we should all make. My colleagues on the Committee on the Future of Healthcare will hopefully support that also.

On the requirement to create new GP training places, we need to be smart in this to correlate the fact that we also need to create capacity and volume for the other professionals needed in the primary care area - whether it is assistant GPs, practice managers, practice nurses etc. - because frankly, we need all of them also. That is an important issue. With regard to the new GP contract we also need flexibility in the type of contract in place. The contract does not have to be the same for everybody. The contract has to be fair and equitable but the same type of contract that operates in one location may not be necessary in other locations. There are many differences between urban and rural practices. There are a whole range of different factors that can influence that. We need flexibility, be it direct hire contracts or other types. There is one question, however, that I would like all six of the delegates here to answer directly. This involves a figure - I am a very straight talking person as everyone knows - and I do not want a narrative on this. What does a GP practising out of Dublin 16 expect to earn in one year in 2017? What would a GP working in County Tipperary, in example in my home town of Nenagh, or in Ballina or Killaloe in my constituency and the Chairman's, expect to earn in a year? Taking into consideration the costs etc., what would a GP expect to earn? The public would like to know that and I would like to know that so we can measure information during the process we must go through on the GP contract. What are the expectations of GPs? It is a critical question. Chairman, I am nowhere near finished. I have a serious issue with the timeframe on this, which I believe needs to be set out and shortened. I agree with the comments that were made on the requirements for community health, the integration of this with GPs, how they are operating and the diagnostics. I will not go through all of the topics because they already been commented upon. We also need to look at our capacity to bring in GPs from outside the State. Somebody needs to talk about this. It is unfortunate but there is going to be an interregnum where we are not going to have enough GPs, even if we were to solve this in the morning. There will be a period of time required for the upskilling and training of these doctors.

I would like to find out some statistics on how many doctors are actually not practising. How many GPs who are fully able-bodied and under retirement age - or around it - are not actually practising? Why are they not practising? What are the consequences of this in the areas where they are not practising, such as in Limerick? In the opinion of each and every witness here today, is it acceptable for GPs to bring in locums and pay them to run their practices? I would like the witnesses' opinions on this. In principle I agree with my colleague, Deputy O'Mahony, on the issue of the co-ops but I am beginning to wonder a little bit about co-ops. There are issues, which the Chairman knows about, in west and east Clare. With my health hat on I have an interest in them all but I am especially interested in the issue in east Clare because I actually use the co-op in Killaloe. I live on the Tipperary-Clare border, more or less. We had a situation where 12 doctors were involved in a co-op and two left, one retired and one moved to Limerick to fill a position - probably the issue I spoke about previously. The co-op's out-of-hours service reduced from 58 hours to eight hours. In that scenario GPs lose local support and local authority. The current GP contract, I accept, should no longer be in place and is completely out of date, but GPs have a responsibility for out-of-hours services because of this contract. That sort of behaviour is not good PR for GPs. Granted there are many issues there, but is it acceptable in the view of the witnesses?

I spoke earlier about the differences between rural and urban practices, the allowances available to doctors and that, for instance, there would have to be some form of allowances for certain costs. I understand that. Surely, however, they should be phased out over time? Have the representatives here today any comment to make on the whole area of pathway management to acute care? Pathway management to acute care is a critical issue. I live in a town, Nenagh, which has a minor injuries unit and hospitals in Limerick are bursting at the seams with the volume of referrals. I do not understand why the minor injuries units cannot take greater volumes than they currently do. This would alleviate the situations such as in Limerick.

It is very important that any future contract is managed. Any future GP contract would need to have a reporting system to the HSE and to the public, based around performance of GPs. For instance, without naming any names obviously, the management information would measure the volume of referrals each GP makes to an emergency department every month, week and year. When ambulance personnel come to me - and I will not say from what area or town - and talk about the volume of referrals in the same town from one GP versus another GP, it sets off alarm bells for me.

The demographics are the same as is the volume of people using each GP. Why, then, is there a difference? While there could be reasons, we have to find out. At least, with that management information, others could investigate. That sort of stuff needs to happen.

I am in complete agreement on the Carlow-Kilkenny model and the integration there. Do our guests expect that to be possible everywhere else around the country given the unique geography of some areas, etc., and the provision of the services available in those areas?