Mr. Val Moran:

I thank the Chair and the IMO thanks the committee for the opportunity to discuss the issues facing general practice. No more than many other areas of the health services, general practice has been facing a capacity issue for more than a decade. At the same time, patient has demand increased and, for a large part of the decade, funding has decreased. For many years the IMO, the ICGP, the HSE and the Government have commissioned independent reports that have highlighted the problem with GP numbers and identified the required number of GPs to meet the needs of patients. We have yet to significantly address solutions that will drive change.

Covid has exposed the fragility of our health service but the pandemic did not cause the problems. In the main they were caused by significant cuts to funding during the years of austerity. The budget for general practice was cut by €120 million, and it is only this month that the final phase of restoration is being paid. It is being paid over a period of three years but it is only this month we are getting back to 2008 levels.

Despite the lack of funding, GPs and their teams have continued to care and, more importantly, provided the continuity of care which is associated with better health outcomes, equity of access and more appropriate utilisation of services. Patient satisfaction with the service is still high but we know there are issues with access in some areas where GPs cannot safely take on new patients. There are large parts of the country where the number of GPs is not adequate to meet the needs of an ageing population. Capacity has to be addressed. We have to look at all the factors affecting capacity while at the same time ensure we do not overburden the service.

How many GPs do we have and how many do we need? Approximately 3,500 GPs practice in Ireland. This can be broken down further to 2,500 who hold a GMS contract, which is the medical card contract, 500 GPs who hold other publically funded contracts, such as primary childhood immunisation and maternity and infant care, and a further 500 working outside of publicly funded contracts. This is an average, therefore, of 0.69 GPs per 1,000 population when we require 1.1 GPs per 1,000 population. The distribution of GPs is not uniform. Some areas of the country have a much lower ratio of GP per 1,000 population.

Numerous studies show that the greater the number of GPs per head of population the better the health outcomes, including lower rates of overall causes of mortality. The most recent analysis of medical workforce requirements from National Doctors Training and Planning estimates that an additional 1,260 to 1,660 GPs are needed by 2028 to meet the needs of population growth, in particular the significant growth of those aged over 65 and those aged over 85 who are naturally high users of the service. We have a growing percentage of people in these older age categories and they use the services a lot more and place much greater demands on the service.

What are the issues driving these capacity problems? The demographic trends in general practice no more than the rest the population are stark. A growing proportion of GPs are over 60 with one fifth due to retire over the coming years. There are high levels of burnout and stress associated with the demands of the service. Many GPs are unable to take sufficient annual leave or appropriate sick leave. A recent IMO survey on mental health and well-being found that 59% of GP were unable to take time off due to difficulties with sourcing locum cover for annual leave and 66% said they were unable to take sick leave. This is a huge number unable to take sick leave. Two thirds were unable to find a locum to do so. The stress and burnout that comes with this pressure is quite high and contributes to people leaving general practice earlier, which builds the capacity problem. The lower the number of GPs the more difficult it becomes to get a locum. It is almost self-perpetuating.

For young GPs, there is a high risk burden associated with setting up a practice. There are significant start-up costs relating to premises, IT staff, medical equipment and other overheads. The risk burden with setting up in practice initially is huge. A significant financial cost has to be incurred and many younger GPs are not in a position to take on that risk. There is insufficient support for hiring a fully functional GP team. This team includes assistant GPs, practice nurses, healthcare assistants, allied health professionals and administrative staff.

There is increased demand coming through also. There is a lack of referral options to other services in the acute and community setting. This means GPs have to manage patients in the community who are waiting for specialist care. We know that 900,000 people are on some kind of waiting list. These patients require care for their condition while they await specialist treatment. In the large, this has been dealt with in the community. There is no real control over demand unless patient numbers are reduced. We see that GPs are closed to new patients in certain areas because they simply do not have the capacity to meet demand or safely care for those patients. Whatever Government policy is on access to GP services it has to be introduced on the basis of sufficient capacity and appropriate supports and funding.

There are potential solutions and I will outline a few of them briefly. A key point for us is supporting and establishing GPs. Earlier I spoke about the risk burden. We have to acknowledge the factors that are an obstacle to establishing practices and develop a model that will allow GPs to start off their careers and support them in this. We seek an enhanced range of supports including but not exclusively tax relief to assist in the funding of premises for critical equipment, infrastructural equipment including IT systems and medical equipment. A number of years ago, an Indecon report recommended tax incentives in this manner and we fully support this recommendation. We call for partnership pathway support funding to allow an existing GP to take on an assistant, who would then enter into a succession arrangement with the GP to take over the practice over a number of years on a phased basis.

The GP may be close to retirement. Rather than the list being advertised and nobody applying for it or an issue arising with succession, the GP is able to have an assistant for a number of years who will then take over that practice.

We need to broaden the GP practice team. Supports are available at the moment. There is a practice nurse and practice subsidy support for GPs in the GMS. These were established in the late 1980s or early 1990s. General practice has moved on a lot since then. Additional staff, for example, healthcare assistant grades and allied health professionals, could be taken or a GP may want to have access to physiotherapy, counselling and pharmacy supports within the practice. There is a need to broaden the supports available in terms of practice subsidies.

Regarding the workload and structure programmes for delivery of healthcare in general practice, we should certainly be looking at defined models of care. The chronic disease model has been a great success. To meet the needs of large cohorts of patients in a structured and proactive manner, it is critical that we expand this programme and that other structured programmes are introduced. The area of women's health, which has long been neglected by the State, is a priority for us. We believe a structured programme dealing with reproductive health, including contraception, maternity care and menopause, should be developed in general practice. Fragmented care is not good for the patient, taxpayer or service.

The out-of-hours commitments are also a significant barrier to people entering into general practice. GPs effectively have to fund the cover provided to patients outside of normal daytime hours. They do this by doing shifts themselves and paying locums for red-eye shifts. This is a factor for people going to certain areas in that the area may have an onerous out-of-hours rota in place. The system has evolved from the initial requirement, which was to provide access to urgent care outside of normal hours, to a routine service outside of normal hours. A national review is required to ensure it is not an onerous burden for GPs, it is equitable across the country and that the model provides safe access to urgent care.

Tied into that, there is an issue with locums, which has long been flagged. I talked about being unable to take sick leave and annual leave. That is obviously not safe. It is not desirable for GPs to work beyond capacity and it obviously deters people from taking up practice in their own right when they are unable to take leave. Responsibility for sourcing and funding locum cover currently lies solely with the GP. Given the huge difficulties and costs associated with this for the GP, the HSE needs to take a much more active role, where necessary, by securing locum cover in certain instances and ensuring that GPs can take leave.

General practice is a rewarding career. However, if we wish to make it attractive to the next generation of doctors and ensure the ongoing delivery of high-quality GP care to patients in their communities, we must address these capacity issues now. We have talked for more than a decade about these problems. We have produced endless reports. There is no single quick fix. A suite of measures needs to be taken and addressing the problem will require significant and ongoing funding. The time to plan and invest was probably ten years ago but the next best time is now. I thank members for their time. We will be happy to address any questions they may have.