Simon Harris (Wicklow, Fine Gael) | Oireachtas source

I thank the Chair. I will try to be quick as I know the committee is tight on time. I agree fully with Deputy Harty. One of the crucial terms of reference of the committee relates to the decisive shift to primary care. I have been very clear in my view that one cannot do that without a new GP contract. I add that GPs are not the only part of the very important shift to primary care. There are also advanced nurse practitioners, community nurses and many other specialties including pharmacy, dentistry and a range of therapists. However, a new GP contract is needed. The current contract is not fit for purpose because it originated 44 years ago and while it has been tinkered with in many ways, it has never been changed radically. A great deal has changed over more than four decades.

While Deputy Harty does not fully agree with me on this at all, I have tried to be more inclusive than any negotiations with GPs have ever been before. Even by his own declaration, the fact that Deputy Harty is a member of the NAGP and the IMO is interesting in and of itself. I wonder how many replications of similar GPs there are across the country. Certainly, I have the impression anecdotally that a lot of GPs are in both organisations. The reality of the situation is that there is a framework agreement between the IMO and my Department on the negotiation of GP contracts. I am respecting that framework agreement which it is important to do in this industrial relations environment. I believe in honouring agreements and that one says we must negotiate with the IMO. However, I have not just done that. I have brought the NAGP into the process for the first time ever. Deputy Harty will remember that it was excluded from the under-sixes contract. If one looks back at the record of the Houses, one sees that some responses to parliamentary questions suggested that the NAGP would never find itself sitting down with the Department of Health and the HSE. I am now finding a formal consultative role for it and I am willing to work with it on the formalisation of that role. Over time, let us see how that role develops and evolves.

While I agree that there needs to be a significant change in a new GP contract, it will not be a static document. I do not expect that we will negotiate now and that a Minister in 40-something years will have another conversation. This is an evolving process. I am due to meet with the NAGP shortly and look forward to having a fruitful engagement with its representatives on the issue. The ICGP is a slightly different body because it is the college. I note the Chair referenced that as well. I have had a good meeting with the ICGP and, while it does not negotiate for its members, I absolutely see a role for it in terms of feeding into the process. We will ensure that happens during the consultative process too.

Deputy Durkan is consistent on the issue of democratic accountability and he is right to be. We must ensure that whatever structure we put in place includes a way to provide democratic accountability. I will answer the Chair's question on my views in that regard in a second. I am not proposing in my contribution today that we go back to the health board structure and rip up all that is good about the national structures. There is a balance to be struck between devolved local decision-making on day-to-day operational issues and the absolute need for national structures and standards. One will not deliver a maternity strategy, a cancer control programme, integrated care, fair deal or e-health without those sorts of things.

There is a clear need for more beds in Irish hospitals. I am not suggesting otherwise. What I suggest, however, is that it is not a panacea as I have seen in hospitals this winter, including in one where we opened a significant number of beds. It provided temporary respite in terms of trolley numbers and then they flared right back up again. We must recognise that a bed is not the same as something the members or I would sleep in at night. It is much more complex. What type of bed is it? Is it an ICU bed, a rehab bed, a community bed or a general surgical bed? There are lots of different beds and where they are located within the health service, the community or hospitals is something we need to examine. There are also other ways to create capacity and if we make it about bed numbers only, we will let people off the hook in that regard. On predicted data discharge, it is inappropriate for a patient to go into a hospital today who is fit to go home on Saturday but who, because the work has not been done to ensure he or she goes home, ends up stuck there until Monday. He or she no more wants to be there than he or she needs to be there. Predicted data discharge provides capacity and hospital length of stay activity based funding encourages more procedures to be done on a day-case basis also. This is somewhere we can evolve. The Deputy is dead right on demographics. We must plan not only for the present but for very different demographics, in particular in relation to chronic disease and older people.

Deputy O'Connell mentioned geographic alignment. I am one with the committee on this. Where those alignments happen and how one draws lines on a map is probably not a question for now, but I agree on geographic alignment.

On clinical leadership, I share the view that clinicians have a greater role to play in terms of management, but that is as part of a team. They cannot just be independent republics. They need to be answerable and accountable. Just because one is a doctor, it does not mean one cannot be a manager, but it is also the case that just because one is a doctor, it does not mean one will be a good manager. It should however be seen as one of the viable options for managing the heath service and parts of it rather than just something we do in the maternity services and which some perceive as being of a different era in terms of structure. It is a valid structure that should be looked at.

The way one ensures that primary care is not seen as secondary, if that is not ironic, is to put specialists out there. In the eyes of the public, primary care is probably seen as a matter of going to see a GP before going to a pharmacy to get medication and returning home. We are about to do work to put advanced nurse practitioners and specialist nurses in the community. Currently, one must go to a hospital to see them in relation to a number of chronic disease conditions. It is a step in that direction.

I agree that the under-six contract was good. If one is talking about primary care, one needs to extend universality. One has to start somewhere. Starting with our children makes sense. However, there are lessons to learn in terms of how it was rolled out as I have heard very clearly from GP organisations. We need to ensure that the capacity exists within general practice.

Deputy Josepha Madigan referred to a phased approach as opposed to the big-bang approach. We would all love to get to where we want to go by tomorrow. However, recent history sounds a number of alarms in that regard. Saying "I will abolish the HSE", as has been said in the past, turns out to be a great deal more complex than it sounds. The decision to put in place hospital groups proved to be a lot more complex than it sounded. Changing the model of funding ended up having to be abandoned. Setting up the HSE did not work out as anyone expected, albeit it was a well-intentioned idea. There is no way to do it other than by way of a phased process. This would be a committee for a six-month health vision rather than a ten-year health vision if that were not also the Dáil's general view.

On the Chair's questions, it is fair to say there is currently a perverse incentive. I tried to allude to that in my speech. One gets paid more for treating a private than a public patient. I am not sure how one could describe that other than as a perverse incentive. The 1999 White Paper outlines the drawbacks of that but also outlines some potential benefits in terms of consultant retention and the like. These issues need to be teased out in a great deal of detail. There are measures one can take relatively quickly to remove the perverse incentive while having the broader longer term discussion.

There was a reference to how we wanted to place the hospital and community groups on a statutory footing. I would very much welcome the committee's views on this, but I envisage that this will be underpinned in legislation and that a board will be appointed. Obviously, we have hospital groups on an administrative basis with the idea of boards on an administrative basis, but it needs to be made statutory from a governance and proper accountability point of view. We need to consider in advance of drafting that legislation what we are devolving to groups and what we are retaining at the national level.

On the issue of clinicians, I fully agree with the Chair that clinicians are and should be seen as part of the solution. We cannot make people better without them. At the same, however, they have to be accountable in terms of their own work practices. As I said in the speech, there are issues in relation to pay and tax that people raise when one talks about recruitment and retention but hand in hand with those discussions must go responsibilities, new functions and new roles. As such, I am interested in exploring Professor Keane's idea further.