Professor Tom O'Dowd:

I thank the Chairman and members of the joint committee for inviting me. Lest it go unmarked, it is nice to spend part of St. Valentine's Day with all of them. Members may be punch drunk on figures at the end of this, but I will try to keep them as straightforward as possible. I have just circulated the report to them and it is also available on the websites of the HSE and Trinity College Dublin. It was commissioned by the HSE with the involvement of the Department of Health to review how primary care systems operated internationally. It includes a big chunk of patient consumer research about general practice and also targeted interviews with key individuals in the wider health service.

Reform of the primary care system has been on the agenda for years. I have attended many meetings at which a Minister said, "Yes; this is the way it's going to be." However, the current system remains fragmented, poorly developed and unfair. Achieving reform in the health service requires a decisive shift towards general practice. For this shift to occur, it needs a change in the contractual arrangements with general practitioners. I would be misleading the committee if I did not convey the sense of brittleness in general practice. I have spent many winters in general practice and this one has been very difficult. Many of my colleagues reflect the instability that is emerging in general practice.

The overall spend on general practice in Ireland in 2014 was €858 million, the same as the amount spent on running St. James's Hospital. Approximately 42% of the population is covered by the GMS. The vast majority of GPs' income, 63%, comes from the GMS, with the other 37% coming from private practice, but that figure covers nearly 60% of the population. On average, GMS patients consult 5.63 times year, which is more than the figure for private patients. Although they are more ill, the divide is not great and it is much more of a spectrum than we realise. In compiling the report which took us a year we estimated that 4.5% of the entire budget was spent on payments to GPs. This is the lowest percentage in all of the comparable countries we studied. The role of private health insurers is underdeveloped in Irish general practice and almost non-existent. It is a secondary care resourced system.

On the number of GPs per 10,000 population, the number in Ireland is broadly similar to that in Denmark, Germany and the Netherlands but significantly lower than that in Scotland. One would not think that if one were in Scotland, but it is lower. Countries that are rated highly on access and services have higher numbers of practice-based staff. The key seems to be having practice-based staff, including practice nurses, physiotherapists and pharmacists. However, Ireland has the lowest number of practice-based staff in the countries at which we looked.

We are focusing - I think the State is also doing so - on chronic disease management, for which a better term is long-term illness. Anyone who has just had a single disease at any of our ages will have lived a pretty charmed life. Most people will have more than one and they are not diseases that can be managed by the same drug. They need a variety of medications. Most people over 60 years have two or more diseases which, unfortunately are well advanced. There is good evidence that seeing the same doctor regularly results in significantly fewer admissions for patients. That is an important finding which was published last year in the British Medical Journal. Seeing the same doctor on eight or more occasions in the year resulted in 12.5% fewer admissions. That monetary value can be attached to it, but, of course, it takes time.

The survey of patient satisfaction levels was carried out online and by telephoning patients who had recently visited the GP. The satisfaction rates astonished all of the GPs who were very defensive about satisfaction surveys being carried out at the time. More than 90% of patients were satisfied with their last visit to the GP and prepared to go on a waiting list for a recommended GP. Word of mouth is very important in Ireland. Ease of access to appointments was also rated highly, with most parents of children being given priority. The comments were very positive. People said they had gone along without an appointment but were fitted in. Therefore, there is a child-focused approach adopted by GPs. Based on research in which others and I have been involved, we know that the cost of seeing a GP deters one in three patients. The figure is highest among those paying for the service and younger patients.

One of the big successes in the past decade has to be the out-of-hours services. Over 1 million out-of-hours consultations are provided per year. Out-of-hours work is not easy; it is the mucky end of the stick. It occurs after a day's work and late into the night, yet it has been hugely successful. Accessibility has also been seen as successful, although all of the co-operatives found it very difficult in the Christmas 2017 period.

GPs have been early adopters of information technology. We use it for the recording of administrative, clinical and prescribing details and screening programmes. We are beginning to make electronic referrals to hospitals, particularly for cancer patients, but the links are a source of concern for GPs. The lab results are quite good and now received electronically.

Diagnostics, in particular, have got worse. For the past 30 years I have been involved in a longitudinal research study of general practitioners.

The last time we did it, which was approximately five years ago, access to diagnostics had actually deteriorated. It is not possible to run modern medicine without access to diagnostics, by which I mean X-rays, ultrasound and MRI scans and so on. Access has actually decreased for public patients. In fairness, the cost of MRI scans has come down but families still often have to club together to pay for a scan.

When we did focus groups with our general practitioners in training, one reason they said they would not stay as general practitioners was the clinical disrespect they felt from being unable to have access to diagnostics. We cannot underestimate that. We train GPs first as doctors and then as GPs. If they say they are going to go to psychiatry or clinical medicine or whatever because they cannot practice as a doctor, then there is major waste in our system.

GPs in training do not see themselves as single-handed practitioners. The number of single-handed practitioners is reducing. When I started in practice, it was the norm that a person set up in practice. The numbers for single-handed practitioner are coming out at approximately 18% and they have fallen considerably. Yet people are fond of a single-handed practitioner who knows them. Anyway, younger doctors do not see themselves in this light. The job has become too complex and they want colleagues.

Many are unwilling to take on a General Medical Services contract because it is so complex. It requires a great deal of attention to detail. There are risks to being an employer as well. I am an employer of staff and I worry about keeping them afloat. Income is tight and the past ten years have impacted on sole traders and small practices. Many of our younger GPs say they do not want it. They have said to us that they are interested in being salaried GPs when they come out and then would like to move into partnership before becoming managing partners. It is a little like the law firms, which have a similar model.

The heroes in the consumer studies were undoubtedly the nurses. Practice nurses rated highly. They are seen as central to developing high-quality services. They are great consumers of further education. They see themselves playing a role in long-term illnesses. They are a great source of security to the patients, especially those with chronic illness. We have had a great deal of representation from the pharmacists. Pharmacists see themselves as being able to share some of the aspects of chronic disease management with GPs. As it is, community pharmacists play an important role in medicine safety and preventing drug interactions. The most common interaction I have as a general practitioner is with my local community pharmacist, who looks out for me and for the patients.

Clinical pharmacy is being developed in the National Health Service. It really is an important adjunct and ingredient in the management of chronic illness. The professionals are employed by the practices. They are not involved in the retail end but in the management and provision of medications. Medications have become more complex. This allows the GP to focus more on the medical aspects. It is not uncommon for patients to be on ten medications. That can happen easily and many of these medications interact.

I wish to comment on allied health professionals. It is interesting to read the literature and to interact with physiotherapists, occupational therapists and psychologists. They want far more interaction with patients in primary care. They realise that by the time patients get into the hospital sector it is too late, especially for intervention by allied health professionals. Behaviours are set. Diseases have advanced, even diseases that can be prevented. They are open to working in primary care, which is the pattern internationally with these professions.

Inevitably, every time anyone appears in this room they are asking for more money. That seems to be the modern way.