James Reilly (Dublin North, Fine Gael)
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It is not so much that they are refusing but that they just cannot afford to go, as the Chairman said. It is also a question of the cost of the care. This is why we want to extend free GP care to the entire population.

The value of 2,000 medical cardholders to a GP's practice is approximately €500 million. Many expenses must be paid from that but, none the less, that is the position. The value of 2,000 private patients, with an average visitation rate of 2.5 times per annum, at €51 per visit, is approximately €250,000. Therefore, having free GP cardholders automatically increases the income of a practice. I do not envisage us paying the practitioners any more; rather, I envisage tough negotiation on how they will be paid, what they will be paid and the sort of work they will be asked to do.

On my tour around the country, I said to GPs, in the knowledge that we must negotiate with their representative organisations, that the bottom line is that if we change the model of practice, the manpower issue in general practice will not be as acute as it is at present. It is worth saying publicly that consultants are seeing patients that GPs should be seeing, and there are GPs who are seeing patients that nurses could easily see. Nurses are looking after patients that health care assistants and others could deal with. I will refer to the INMO report in due course.

If all patients had free GP care, there would be no reason a practice nurse could not see them in the first instance and make a professional decision as to whether they needed to see a GP at all. Many patients who attend a GP at present will find the practice nurse can deal with them just as satisfactorily. In this regard, consider the number of patients who present with upper respiratory tract complaints and the number of children who present with high temperatures. Most of these illnesses are self-limiting viral illnesses that a nurse could deal with without any difficulty. Some will require the doctor, and the nurse is perfectly trained to decide who those patients are. Most chronic illness care could be delivered by a practice nurse, with the more complex cases referred to the GP. By having the right person treating the right patient in the right place at the right time, we can improve the system without it costing a fortune.

Deputy Kelleher will be aware of the circumstances in St. Mary's in Cork, which I mentioned. The physiotherapists screened all the patients coming to the orthopaedic clinic and found that 50% of them could be dealt with by the physiotherapists themselves. This does not mean that doctors, GPs, do not know what they are doing; it means that, within the current system, a public patient who cannot afford physiotherapy needs to be referred to the orthopaedic clinic where he can obtain physiotherapy at a cost he can afford or at no cost. This is utterly inefficient from the perspective of the patient and the authorities running the system.

Consider the number of people who fail to turn up at outpatient clinics for appointments. There is a considerable number of outpatients, amounting to 385,000, but we need to put that in perspective because we know 200,000 are seen every month. Non-arrivals are due to a number of factors, one of which is that if one is waiting two, three or four years for an appointment, one will forget about it. Alternatively, one may have been treated elsewhere. It is desirable to text the patient a week before an appointment with a simple request to text back, using the letter Y or N, stating whether one can attend, and to text the patient again on the day of the appointment with a reminder. If patients who are contacted do not turn up, we should charge them at least €20 on the next occasion for failing to keep their appointment, which failure will have deprived somebody else of the service.

The corollary - I said this to those in the system and they agree - is that it is utterly disrespectful and gratuitously insulting to patients to call 30 people together for a 9 a.m. appointment at an outpatient clinic.