Dr. Brendan O'Shea:

These are important questions. I will address the question about GPs with a special interest: life is a bowl of toenails. Some of them attract perverse incentives for removal. Let us suppose I send one of my patients to a private hospital. The cost of the procedure by billing through private health care will end up in the order of approximately €500. This includes a greater fee for the surgeon and there is an anaesthetist on stand-by in case anything goes wrong in a clinic room. If I do it for a patient under VHI cover, it will cost approximately €80 or €90. If I do it on the medical card system on the public side, the public patient gets the thin end of the wedge and the cost comes in at approximately €38. Therefore, I cannot do it for the public patient. That was twisting me up inside, so I stopped doing them. We have carried out surveys of the members of the college. Approximately, one quarter of our GPs are keen and interested in developing special interests. A doctor with an interest in diabetes in a four-doctor practice could really lend an edge. It is a question of manpower: we are short of the doctors to do it.

I will move on from toenails. The next question was about the disconnect between hospitals and GPs. We are working on this. We know what we need to do.

Those of us going back to busy surgeries need to be able to engage. We are looking at local integrated care committees. This can be done elsewhere. Part of it is a question of manpower. It is difficult to get out of our surgeries. The minute anyone leaves the surgery, the practices immediately start running at a loss in a material way. It is not only a financial thing. Patients need to be seen. We need more doctors and practice nurses who can do work we are doing at present.

We know what needs to be done. We have had different people looking at our system. I am keen to highlight one of the observations. It comes back to the point about the chaos outside University Hospital Limerick and the ambulances. One issue is the gap at regional level. We work hard in our surgeries. Our specialist colleagues in public hospitals work appallingly hard in the public hospital system. We do not have the mechanisms to integrate on a system-wide basis. There are isolated examples. Everyone refers to the arrangement in Carlow and Kilkenny. The consultants and GPs there put in the extra hours to put something in place and they got funding for it.

Much of our funding at the moment is delivered in a manner that is exquisitely sensitive to budgets. It is control-centred. An overview of our system suggests we need more autonomy in regions, towns and villages. We need more direct involvement with clinicians. However, for that to work, we need more clinicians.