Dr. Ray Walley:

The Irish Medical Organisation thanks the Chairman and the Joint Committee on Health and Children for the invitation to present our resource general practice campaign, Help us to Help More. The IMO launched the campaign in November 2013 to highlight the potential for general practice to do more for the health care services and how we can do so with careful planning, adequate resources and meaningful negotiation. General practice can deliver 21st century care that is free at the point of access to all patients.
What is good about general practice? We have 2,414 GPs delivering care to almost 2 million General Medical Services patients. A total of 24 million clinical consultations take place every year with 1 million out-of-hours consultations also taking place. A total of 95% of all consultations are dealt with by a GP without the need for referral to secondary care. We are there when patients need us. We deliver a same-day service, 24-7, 365 days a year. GPs are committed to change and development.
A number of issues arise with general practice. The workload has increased while resources have been savagely cut. The number of patients with medical cards and GP visit cards has increased by 500,000 over the past six years while resources have been cut by €160 million per year, which is a cumulative total of €434 million. This is a reduction of 38% in funding to general practice, compared with an 18% reduction in other parts of the health care service. The Government spends just 2.3% on general practice out of total health expenditure, public and private, compared with 9% in the UK. Practices are struggling financially and in terms of capacity. GPs are frustrated with an out-of-date 40 year old contract. Since the Competition Authority intervened in 2006, general practice has stagnated and there have been no new initiatives or developments. There has been no engagement. Morale among GPs is at an all-time low. There is a serious manpower crisis. Young GPs choose to emigrate while older GPs see no viable future.
I have included a number of quotes from a professor of general practice and primary health care in the US, Barbara Starfield. She stated that evidence-based studies show that primary care, in contrast to specialty care, is associated with a more equitable distribution of health in populations, a finding that holds in cross-national and in-national studies. She also stated:

The supply of primary care physicians was significantly associated with lower all-cause mortality, whereas a greater supply of specialty physicians was associated with higher mortality. When the supply of primary care physicians was disaggregated into family physicians, general internists, and paediatricians, only the supply of family physicians showed a significant relationship to lower mortality.

The term "primary care physicians" is from the US and our equivalent is "general practitioners".
General practice is at the centre of strong health care systems, such as those in the UK, the Netherlands and Denmark, where access to GP services is provided on an equitable basis across the population and where a greater proportion of the health care budget is spent on GP services and ancillary primary care services. The Government's goal is to deliver GP care which is free at the point of access to the total population. The IMO is in the vanguard of supporting this, but it requires careful planning, appropriate resourcing and meaningful negotiation.
Planning for the provision of GP services free at the point of access requires careful analysis of demographics trends. Ireland has an ageing population and, by 2021, there will be an extra 200,000 people over 65 years of age. It also requires careful analysis of manpower needs, including the required number of GPs and other practice staff per 1,000 population. Priorities based on medical evidence must be established. Clinical service and visitation rates must be defined. Visitation rates are higher among older people and those with long-term conditions. In addition, visitation rates increase when access to GP care does not require out-of-pocket expenses. The ancillary workload must be defined. Realistic timelines for implementation must be developed with appropriate cost analysis.
Appropriate resources for general practice are required to ensure sufficient manpower levels. Ireland is facing a shortage of GPs. Approximately 240 GPs, or one in eight, in the country are 64 years or older. More than 4,000 doctors are registered in the United Kingdom and the majority are general practitioners. Over the past four years, 1,049 Irish-trained GPs have taken up general practitioner principal posts in the National Health Service. We need appropriate levels of medical, nursing and practice support staff. Successive cuts under the Financial Emergency Measures in the Public Interest, FEMPI, Act have led to cuts in employment hours of practice staff. We need access to allied health and social services in primary care. At present, waiting lists apply to access to all allied health and social services in primary care for GMS patients, and many of these services are simply not available for those without a medical card. We need appropriate infrastructure. Premises, medical and diagnostic equipment and IT requirements must be fit for purpose. The real and specific needs of rural and deprived areas must be provided for. Allowances should be made for opt-in to enhanced services as many GPs have training in other specialist areas.
Free GP care requires real negotiation. Since the inception of the GMS in 1972, the IMO has negotiated with Department of Health and the HSE publicly funded contracts which have stood the test of time. These include the GMS contract, the mother and infant scheme, GP visit cards and out-of hours co-operatives which have delivered value for money to the State, quality services for patients and a service that works. GP services have a 97% patient satisfaction rate.
Negotiation benefits all parties. The Department of Health will acquire GP knowledge and expertise as to what can work in general practice.

It ensures GPs can deliver care in a safe, effective and sustainable way, patients remain at the centre of care, legitimacy is enhanced, implementation is smooth and delivers a standard and equitable service to all patients, and both parties have an interest in making it work and ensuring success.
The Government is fully aware that legal proceedings are being initiated by the Competition Authority against the IMO. The position is that the IMO is a registered trade union with a negotiating licence and, therefore, is entitled to fully represent its members in all aspects of negotiation. The position of the Competition Authority and the Government is that the IMO cannot negotiate on behalf of its members on price. A former Attorney General, Mr. Paul Gallagher, stated the following in 2012:

I believe that the Competition Authority's position is wrong as a matter of law and that this stance has created significant uncertainty on the part of the representative bodies with regard to what they can and cannot do and has created significant difficulties for Government in implementing the necessary changes. ... GPs were all charging the same fees to the Government for the medical card services and therefore the idea that they were somehow combining on price by entering into negotiations is difficult to understand. There was never any prospect of the Government being able to negotiate independently with GPs to achieve differential pricing.

That shows that there is no impediment to negotiation and it is in the interest of all parties.
The IMO calls on the Government to do the following: agree a strategy for the development of general practice services for the whole population with a focus on extending the range of services provided, provide adequate resources to support the strategy, and agree an action plan to address the manpower needs in general practice.
The importance of general practice is evidenced in Holland which has invested in general practice for 30 years. That underpins the provision of universal care in Holland and acts as an appropriate gatekeeper. The international belief is that the system works but needs resources.