Mr. Liam Doran:

It is a little like the Chinese proverb: "If I wanted to go there, then I would not start from here". Let me be clear: we cannot and will not deliver Sláintecare and a universal accessible primary care system under which all health professions will be utilised if we approach it with the current model. ICTU's view differs from those of the other contributors that the committee has heard today. We have a system under which some people are entitled to care paid for by the State, while others pay for it, but we are trying to introduce universal access. Why would one have independent contractors in a small business model providing a universal accessible primary care system? What profit would be generated by it?

As we stated in our original submissions, it will take more than ten years to implement Sláintecare. A massive political and societal buy-in is required because Sláintecare is a completely different way of allowing the health service to touch people when they need help.

I will try to go through the points as best I can but my colleagues will bail me out if I leave some out. Mr. Paul Bell will address the questions on home helps.

Practice nurses for GP practices have been needed for years and we are fully supportive of their role. They should be directly employed by the State. There is no salary scale for practice nurses. Under the present model, the GP receives a grant to employ a practice nurse, but he or she may not necessarily pay the nurse that amount of money. They have an individual employment relationship and this can lead to argy-bargy. On top of that, the practice nurse performs services in the clinical area for which the GP gets another fee, whether for the flu vaccine, the cervical smear test whatever. The State is paying for the service twice.

A couple of years ago we conducted a survey and in one practice, our members estimated that they generated income from private patients' fees of €112,000, outside of the GMS income for the practice, based on the tasks they did in the previous 12 months. Our view is that practice nurses should be directly employed by the State and should be entitled to be eligible for superannuation. We agree that their role should be broad so that they have a seamless connection with the community-based nursing services. At present, there is this wall behind which the practice nurse stays. Patient A goes to the public health nurse or the community general nurse. That is not a seamless service. If one is intelligent enough to navigate it, one might get out of it but if not, it creates a problem. The practice nurse should be directly employed by the State, as all people in the system should be. They should be allowed to expand their practice. The current model of grant aid to the GP, which is not reflected in the salary paid to the practice nurse or the revenue that the practice nurse generates for the practice from private patients is neither fair, reasonable nor sustainable.

The fundament point about primary care is that one is not always dealing with sick people, one is trying to keep them healthy or trying to continue the model of treatment that is there. It is not all short-term episodic interventions, rediagnosing and reclassifying, although that is a part of it. What we are trying to do is manage the care of the individual and keep him or her healthy. The advanced nursing practice will have to be the bedrock, particularly in chronic disease management. In general practice in any jurisdiction, the GP will not be intimately involved in the twice or three times a week management of the care of a person with a chronic disease. That is the team's role and that is where the advanced nursing practitioner comes in. The community midwife has a similar role, as the does the community intellectual disability nurse, the community pharmacist, the radiographer, the physiotherapist and the dietician. These health professionals have equal and vital roles to play in a primary care team that is embedded in and serving the community. No one service is greater than the other and they all should be able to take self referred people. The advance nursing practice is part of that service.

The primary care team is the key, but it must be fit for purpose and have good working relationships. Let us fast forward ten years when we will see the impact of the changing demographics on health services. The ESRI has projected an increase in demand of 20% to 32% for services, but not all for acute interventions. The ESRI projects that the demand for home help services will increase by 54%. That is a massive increase. The primary care team has to be modelled, staffed and resourced to deal with the demand on a seven over seven basis.

The Chairman raised the issue of rostering. We would have a fairly strong view on this. The current GP model has the GP providing a service from 9 a.m. to 5 p.m. Monday to Friday and after that one goes into the out-of-hours on-call system and so on. We are very concerned that the development of the out-of-hours on-call system has had a hand in glove impact on the number of people being referred to the emergency departments, who might be treated otherwise in a more collective team-based way. At weekends, in particular, people are being referred because they are seeing a different GP who is a completely new point of contact and there is no continuity of care. That applies to public health nursing and community general nursing services as well. They too are structured on a 9 a.m. to 5 p.m. Monday to Friday service with essential calls only at weekends. We are saying that they should span the seven days as well. If one is truly interested in keeping people out of hospitals then one has to provide a service in the community seven days a week. That is labour intensive but it is the only way. The GP is an integral part of that transition. We are saying that with the changing demographics, modes of treatment and increase in chronic disease management that the team must comprise a group of health professionals with no one specialty having supremacy over the other and no one being a gatekeeper of the other, all referring from one to the other in a much more mature and adult way which does not have as its core a medical model of care that is shaped, directed and conducted by a doctor. That is not the health service of the future.

The health service of the future is different and the team will be central to the care of the individual. We should model the employment relationship as follows. There is no chance that many of the current GP cohort would move to be directly employed by the State. They have their business models, and have mortgages and debts. The only way we will successfully move to a new model is that new GP contracts should be for directly salaried doctors and over a generation one will build up the critical mass of people who will be employed directly. It is the same for consultants. What was disclosed last week in the hospital setting is a direct result of the incentives for practice. One cannot fault people for following the money trail. People are all the same. How long ago did somebody say that people of the same profession never gather without money being discussed. Consultants are no different. We will only get to a directly employed universal health care in hospital or primary care by accepting that the current cohort have a certain contract and as people retire and leave, they are replaced by staff who have been offered a direct public only contract so that in 15 years' time, we have a critical mass of people working completely differently with no delineation between the private and public patients. That is what will be required if we are to deliver Sláintecare, whether in primary care or in the hospital. That is a big ask, but it is the only way this will be done.