Dr. Maitiú Ó Tuathail:

I thank the committee for allowing the voice of trainees to be heard for the first time. I thank Deputy O'Reilly for describing us as the best and brightest. It is nice to have that acknowledged sometimes. No students enter medicine with the dream of emigrating but it is a fact that a proportion of us are leaving. We have data on this. The ICGP does a survey every two years on the career intentions of graduates and graduates who have recently qualified. What they found is that 20% have emigrated; 20% are seriously considering emigrating and 10% do not see themselves working as GPs in five years. Theoretically that is 50% of the workforce gone.

The report highlighted four reasons GPs leave and the committee has touched on those in various ways so I will be able to answer some questions by going through them one by one. The first is their own personal professional satisfaction as doctors. Deputy Kelleher is right that GPs feel helpless. I studied medicine to help people but the health service I work in makes it really difficult to do that. I am tired of opening consultations daily by saying "I am sorry you are waiting two years for the MRI", or "I am sorry you are waiting two years for that hip". As people are waiting they are deteriorating. They are not just waiting; they are coming back to the GP again and again. As Senator Burke said, they are told to tell their GPs to write another urgent letter. I am writing three or four urgent letters a day. It does not make a difference because what happens at that stage is that every letter becomes an urgent letter.

It is extremely difficult, demanding and emotionally draining to work in an environment in which there is nothing to do but wait and write more letters. It makes us, as doctors, feel helpless. I do not want to have the weekly conversation I have with patients when I tell them that they have two options - wait two years for an MRI or pay €300 and have it done tomorrow. Many of them are pensioners and cannot afford to pay that amount. It is a very difficult conversation and, frankly, embarrassing. It strains our relationship with patients. I am embarrassed to be part of a health service that cannot provide access to basic investigations for patients.

Deputy Billy Kelleher is right - we do not feel valued as doctors. Many trainees feel they are unable to do what they spent ten years training to do, at tremendous cost to the taxpayer. We are highly qualified and skilled and assets to the health service, but we will be wasted if we are not utilised. Once I qualify I cannot access basic tests, as Dr. Fawsitt mentioned. If I were to order a chest X-ray today for Senator Colm Burke, it would take two weeks to get an appointment and one month to receive the report, a total of six weeks. I cannot order MRI or CT scans. I have to refer patients to hospital where they must wait to see a consultant, which might take six months or one year. The consultant will say the GP was right, that the patients need a CT scan and they will then be put on the waiting list which will take another six months, all to order the scan that I knew was needed in the first place.

Sláintecare deals with the management of chronic conditions in the community. As Deputy Billy Kelleher pointed out, GPs are skilled and specialised. We have the knowledge and skill to do this work and know our patients. What we do not have is the support and resources of the health service to enable us to do it. As a GP in 21st century Ireland I cannot access the most basic tests. Patients must sometimes be referred to emergency departments because where I am the waiting time for an ultrasound is four months. Sometimes a patient will deteriorate in that time and all we can do is send him or her to the emergency department, which is both very frustrating and embarrassing. We want to achieve our potential as doctors and do what we are capable of doing, but many GPs and trainees believe the system does not allow us to do that. The systems in place Canada, Australia and New Zealand do. They are functioning health services that allow GPs to reach their potential as doctors. It is very little for which to ask.

As Deputy Louise O'Reilly said, we are very concerned about the future viability of general practice. When we are training, we work with senior GPs and see them struggling. They took a 40% reduction in income as a result of the financial emergency measures in the public interest, FEMPI, legislation. It was coupled with a genuinely dramatic increase in workload since the introduction of free GP care for those younger than six years and older than 70. In the out-of-hours service in which I worked over Christmas appointments continued until 5 a.m. This happens when someone rings the doctor to say his or her child needs to be seen. The GP will say the next appointment is at 5.30 a.m. We are coming near to full capacity. The system is at breaking point.

We do not know what the future has in store for us. The FEMPI legislation due to pass through the Oireachtas this week will allow the Minister for Health to alter the fees paid to general practitioners as he sees fit. Since the introduction of free GP care for those younger than six years, banks are far less likely to lend newly qualified GPs like me money to buy a premises because they know that our income can be controlled and reduced by the State. That is a serious problem. Trainees are not willing to commit to taking on a list in Ireland when they cannot plan for the future, given the uncertainty created. Much of the talk is about remuneration, but my generation wants quality of life. An improved work-life balance is something GPs of all ages value, but in order to encourage us to stay, that work-life balance needs to be attained. I know GPs who have not been able to take time off in 18 months. They are technically entitled to annual leave, but they cannot find locums to replace them or to cover for someone on sick leave or maternity leave. In Australia they can.

I am from Leitir Móir on the west coast. When I was young, there were five GPs there and the system worked well. We did not even have an ambulance service when I was growing up. Last year one GP took early retirement because she had to take a required period of absence and could not find a locum to replace her. Incredibly, she was replaced by a young, enthusiastic doctor who recently wrote a letter to The Irish Timesstating one night on call, 72 hours into a shift, he was called to see a man who was unwell. He waited for an hour on the side of the road for an ambulance to come and nearly ran out of oxygen. He was genuinely worried that the patient would die. I do not want to have a conversation like that with a patient telling him or her that there is nothing I can do but wait for an ambulance when he or she could die. As of 2 August, a second GP had resigned, not retired, because the workload was becoming unmanageable and unsafe. It sends an incredibly powerful message when someone who for years was the lifeline for the community no longer believes he or she can do his or her job safely because of the incredible demands placed on him or her. The post remains unfilled. From December it is likely a third GP will take early retirement too because of the impossible demands placed on him.

Doctors are resilient. We endure six years of struggle in college and work all of the hours God gives to help our patients. We are not afraid of hard work and it is rare that we give up. When we do, it should cause serious concern that primary care services are on the verge of collapse. I studied medicine because I hoped to replace my GP on his retirement. Last week he worked 120 hours. He works a one-in-four rota, meaning that every three or four days he will do a 36 hour shift. He works 48 hours every fourth weekend. I am not ashamed to say I do not know if I am physically or mentally able to do that job and face the demands it would place on me. I am in my 20s; he is in his 60s. No amount of money in the world would attract doctors to these jobs. It is not a question of money but increasingly the impossible conditions GPs face. Would any committee member tell his or her son to take up a job in an organisation from which three people have resigned because they believed the workload was unsustainable, unsafe and possibly posed a threat to their health? They would not.

Financial prospects are better abroad. The United Kingdom is approximately ten years ahead of us in dealing with its general practice crisis. There is a huge shortage of GPs in the United Kingdom and they will come looking for GP trainees. We, therefore, need to address this problem now. General practice has changed in that it is attracting graduates. These are ones who have taken out massive loans to become doctors and they are in debt to the tune of approximately €150,000 or €200,000. They need to pay back these loans. They are not being greedy; they just want to pay off their loans in order that they can start a family and have a life during training. They took out the loans to become doctors. That is a complex matter and I acknowledge that Senator Colm Burke is working very hard on the issue of graduate debt. I am not sure what the answer is, but I know that he is working on it. It is a huge problem.

There are four reasons GPs are leaving: they want to be able to work to their full capabilities; they want to reach their potential as doctors; they need access to basic services and diagnostics and they need to be paid for what they do. We are not sure if the specialty is viable. The first step in providing that reassurance would be the reversal of the FEMPI legislation. If we were to be given a new contract which reflectd the day-to-day workings of 21st century practice in Ireland. it would be a huge step for us. We do not want much. We want to be able to take time off. I want to be able to take one or two weeks off when I need to for my own physical and mental health. I know that in many posts such as the one in the place I am from there might be a period two years in which I would not be able to take a single day off. There are not many reasonable people who would be willing to do that. Some of us are heavily indebted and cannot afford to stay in Ireland and know that we will be able to pay back the loans and have a life in moving abroad.