Dr. Ray Walley:

There is a little bit of good news, which is that there was an oversubscription for training posts for the first time ever because the union and the college are doing what they are supposed to do. The State is also doing what it should do and there is a good campaign, the Be a GP campaign, which got people interested. The majority of the workload is done by GPs with a medical card contract, and there are only a small number of private GPs, just 266 out of a total of 2,540. It is 40 years since Professor Barbara Starfield looked at best health care systems and found that, in the general practice-led European system, mainly in the form of the NHS and the Dutch system, morbidity rates and rates of medical complication were inversely proportional to the number of GPs.

The emphasis of general practice is continuity of care. One knows one's GP and can talk to him or her. Much of the service is from cradle to grave and that is still the emphasis of good health care systems. In America at the time, and it is still the case, there was one cardiologist to 10,000 people but its mortality and morbidity rates were atrocious for a First World country. The American health care system remains the system which one must not emulate. It costs a fortune and one gets very little out of it in the way of reduced mortality and morbidity.

The idea was to have GP-led teams. In my practice there are eight staff, including three GPs, one practice nurse and three secretaries. As a business, we run on a 30% profit margin but under the financial emergency measures in the public interest, FEMPI, we had a 40% cut in funding, meaning we automatically had to let staff go. We had to constrain the practice to ensure we did not go bankrupt. For the first time in the history of this State, 120 middle-aged GPs left the country with their families. It is unheard of, but I remember a politician saying that doctors had always emigrated, a very flippant comment that just irritated people. The cuts are still in place and, as a result, general practice has not been able to employ more staff. It is now worse because the people who come off the training schemes are emigrating and it is difficult to get locums. It is difficult to get holidays and that brings more stress to the system. We are not as far gone as some European countries and we could still resuscitate the system.

I have no problem with blue-sky thinking but what I really want is evidence-based medicine, and my patients deserve that. Blue-sky thinking is experimental but it costs a lot. As a vocationally trained GP, my prescribing costs less than that of somebody who is not vocationally trained. The system is based on managing a budget in an appropriate way and that is what happens in a practice. The Irish College of General Practitioners provides organised continuing medical education. We have the same programme, curriculum and methodology so that we treat people in the same way, although we all have different personalities. Anything else is blue-sky thinking and I am concerned that it will cost more money if we do not fund what we should fund.

The health care system to copy is the Dutch system because they have developed general practice over 30 years. They provide 10% to general practice and 10% to community care and they have 85% of their beds full at any one time. They rotate and do not have problems with elective surgery. I am sure the system is not perfect but it is the system to emulate. They retain all their staff and have no training problems. It is not exorbitantly expensive like the American system, where consultants and GPs can earn eye-watering money. Dutch doctors are paid reasonable rates and they retain their staff. The system works and the population is happy. We are at Olympic standard when it comes to producing reports but we are at bronze medal level, or even at the bottom of the heap, in implementing things. We implement nothing. Patients in rural and urban deprivation often have a lack of reading and writing skills and cannot defend themselves. We pay a fortune to fix these people because most of them are public patients. If we carry out preventative medicine and save a person's life by persuading them to have a smear test, it is cheaper than if they get cervical cancer later on. It is straightforward but we do not seem to get it.