Dr. Brendan O'Shea:

I will go in reverse order and take your questions first, Chairman.

The Chair asked about referrals to the emergency department. People who are being referred to the emergency department under these circumstances absolutely do not want to be there. Often, the general practitioners who have to send them in do not want to send them in there either. Under the current system, they go from an experienced general practitioner into an emergency department, which is often exceptionally busy – that is the polite term for chaotic. The person in questions waits and is then seen by a junior hospital doctor. Frequently, there is no specialist on-site. There is specialist backup by telephone. That is the system we are stuck with and with which we operate.

As for the contract negotiations, we are not good at this. The last contract was negotiated 39 years ago and there is no memory or process of any of that. As for where the process is at, we met the Minister for Health, Deputy Harris, shortly after his appointment in August 2016. We had assurances that there would be progress on the contract. Regrettably, we have made the contract negotiations very complicated for ourselves because there requires to be a detailed alignment between the Department of Finance, the Department of Health, the HSE, the college, which is the standards-driven body, and the GP representative organisations. Other important people are involved, including the Irish Practice Nurses Association. We have made this very complex. The job the negotiators have to do is exceptionally difficult. To answer the question, as far as we can understand it the negotiations are progressing very slowly in a relatively opaque manner and in a manner that is of concern to those of us who are particularly focused on patient care. This touches on some of Deputy Brassil's points on building up the system. As each year goes by, a further percentage of our young trainees emigrate. They will not work in a work system that is operating the way it does.

Deputy Brassil asked how we build capacity and what can we do. How do we get to 90 GPs per 100,000 of population? The college has increased the number of places on the national training scheme from 154 five years ago to up to 200. The college is ready and able to expand training, subject to funding and building in training capacity. We believe that, subject to funding, it will be possible to increase capacity. This year there has been a marked increase in junior hospital doctors applying for places on the national training scheme. We are positive in that regard.

If there is a new contract, it will make a difference. At present, 17% of each class of graduating GPs leave straight away. They leave to work in Australia, Canada and the UK. GPs in these countries have equality, electronic health care and appropriate processes of referral. GPs in these countries do not have to send their patients into chaotic emergency departments and they are paid reasonably well.

If we have a better contract, there is a prospect that the groups who have emigrated in recent years may come home and that we would be able to retain more of our well trained and well qualified general practitioners.

There is another element to fixing the problems that relates to the capacity for practice nurses. I am keen to highlight the situation of practice nurses in the health system at the moment. They do not have uniform access to maternity leave or educational leave. They have no career progression pathway. In general terms, their terms and conditions are significantly limited relative to their colleagues in the hospital setting. We have 1,700 practice nurses who work incredibly effectively. They are all electronically enabled. It is known exactly what they do, but it is very difficult to recruit younger nurses to expand capacity at present. However, if we can equal the playing pitch between practice nurses in hospitals and in general practice, then we are confident that we will be able to increase the numbers of general practice nurses. That would have all manner of attendant benefits that we have referred to already.