Dr. Emmet Kerin:

We have all touched on the question of what we can do immediately to get things moving. Dr. Fawsitt, rightly, pointed out that we were putting nurses into the wrong area in the community and that there was no relationship with general practice. If we could have that changed, it would be an immediate win.

We have to redefine how general practice is run. When we studied the GP home care model in Plymouth, we found that they had changed the ethos completely. They had pooled practices through the use of information and communications technology to create an alliance between GPs and practices and shared resources. They had drawn on the voluntary and National Health Service structure, particularly on the voluntary side. In Ireland there are many voluntary groups, including patient advocacy groups, meals on wheels and social care services.

One brings that into one's practice and one then pulls back on the workload. Much of my workload includes counselling, which is not in my contract, dealing with depression, anxiety and social situations. I write letters relating to the housing crisis and everything in that range of things, so social work is interplaying with general practice. If we create that alliance together, we would achieve an immediate win. We must redefine what our practice nurses do in general practice. They are a significant asset particularly in chronic disease management. GPs are senior decision makers and need to be at the level of senior decision making for complex disease polymorbidity. That is what our role is. We need to move back from signing forms and writing ever stronger letters to argue that a case is more urgent than the last letter that said it was urgent, and start enabling.

We can do that ahead of implementation and the big bang of a new contract but I strongly believe that we now have a sickness model. Deputy O'Reilly asked about the fee structure and was interested in the split. We operate on a capitation model. The public is not aware of this. In my consultation, I do not tell my patients that I get paid X amount a year for their care, which is an open ended system and I receive a dead end payment. That has a huge ramification because the GP is trying to pick up the slack of what is not being done in secondary care and is becoming overwhelmed, which means that inversion happens. After subsidies, the average payment for a medical card is just in excess of €10 monthly per head coming to the GP. How can someone run a business like that? One cannot. It depends on an individual's outlook. In my practice, I augment my income by doing work outside general practice, in occupational medicine, procedures, lecturing and research and I put it all in the pot to deliver for my patients. Many GP practices do that. If one is only getting the State payment on GMS alone, it is not enough. It will end in a situation of getting less for less. We must get down to the issues. There has to be immediate resourcing and goodwill. The budget this year was a huge disappointment, no meaningful transformation fund was put in place. GPs are hanging on by their fingernails and are looking for that support but it is not forthcoming.

Returning to the level of public funding in the country, less than €500 million was put into funding the service. Some €17.5 billion is spent in the health service with 90% of interactions happening in general practice. It does not add up. These are my immediate comments on implementation.