Dr. Austin Byrne:

In regard to the question of where it all went wrong, the answer is perhaps to be found in the question, when did it all go wrong? It all went wrong in 1973, shortly after the new contract was signed. We took the waterfall mentality of roll-out that is very common in public sector contract formation, namely, identify the problem and build current capacity around the need or demand while projecting forward. We cannot do long-range forecasting in health very easily. We certainly cannot do long-range demographic forecasting very accurately. We had a 1970s solution to a 1970s problem and as it rolled on it picked up baggage and excess need such that we currently have clinical unmet need patients who cannot access the services they need. Those patients, because they deteriorate in their clinical condition, tend to spill into services that are above their need.

We also have a huge layer of unmet need in terms of things we need to do that we currently do not do. In addition to GPs to man access to services for patients who cannot access them, we need GPs to man the services that we currently do not even consider to be GP services. As such, we have two layers of unmet need.

FEMPI came along in 2008. Reference was made to the glorious days of the wonderful salaries publicised in respect of GPs. My own practice was regularly listed in the top-ten earners, although towards the end of the list, unfortunately. It all looked wonderful. Included on the list were salaries of €600,000 for a practice in Tramore but that was a meaningless number, a top-line figure. In other words, the figure was the amount of funding provided to run the practice. Much was dependent on the structure of the claim system and the allocation of patients. In our case there were two doctors at the time and a third assistant. If the allocation of patients was weighted towards a single doctor in practice the list would reflect that in a single list number whereas there could be another practice equally-sized further down the road with three doctors but in respect of which the patient allocation, because the three doctors had opted to co-locate, was an equal split such that the payment to the practice was one third of that announced, or €200,000 per doctor, such that they would not make the list. Each doctor could be paid €205,000 such that there would be a higher total net top line income but they would not feature on the list. As I said, the list was meaningless. It should be borne in mind that that list represents top-line gross. For most practices, it would be necessary to take 50% to 60% off in terms of overhead costs and opportunity costs, such that the list would not be reflective of the true picture.

FEMPI destroyed us. The 38% cut in GP salaries was a top-line cut. Operating costs did not change. Patient demand and activity did not change. This leads me to the question posed earlier by Deputy Louise O'Reilly in regard to blood testing. Blood testing in the 1970s most people would agree was a rarity. Blood tests were generally done in an acute emergency. In other words, if a patient was bleeding, blood testing would be carried out to see if he or she had a bleeding tumour. That is very different to the role of blood testing these days and the role of blood testing into the future, which for Ireland, means enhanced near-patient testing. To suggest that a practice currently performing thousands of blood tests per annum should be offering those pro bonounder a capitation system that was never designed to fund them and does not fund them, is very difficult to square. I understand that among patients of lower income that is a barrier to care but there is an obligation on the health service - this was confirmed by Dr. James Reilly when Minister - to provide those blood tests in the local hospital setting. There is no similar obligation under contract.