Róisín Shortall (Dublin North West, Social Democrats)
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I warmly welcome Dr. Ronan Fawsitt, chairman of St. Luke's local integrated care committee, and Professor Garry Courtney, clinical director of St. Luke's General Hospital, Carlow-Kilkenny, who will present us with a briefing on the Carlow-Kilkenny model of care. I welcome them both and thank them for coming along.

I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I apologise for the delay in coming in. We had a long session earlier on. I invite the witnesses to make their presentation.

Dr. Ronan Fawsitt:

We are used to delay in the health service so it is fine. I thank the committee for inviting us today. We are two front-line clinicians based in Carlow-Kilkenny. We are not academics or health economists but we have learned what works. We have also seen what is possible when GPs and hospitals work together. We are not representing any organisation in this submission today but reflecting our own learning and experience gained over nearly three decades of local engagement. We support the committee's vision to transform the health service with a ten-year plan that is agreed by stakeholders and the State. We believe that in this age of digital health new thinking, new care pathways and new relationships between primary and secondary care are needed. Most of all it requires more joined-up thinking and activity in health.

Throughout the country our hospitals, community services and GPs are struggling with increasing demand, finite resources, reduced capacity, fragmented care, an ageing population and the growing burden of chronic disease and multi-morbidity. Our manpower crisis compounds the problem and there has been an absence of confidence and direction in our disconnected health service. Relationships between primary care and secondary care are strained in most areas. The financial emergency measures in the public interest, FEMPI, legislation cuts which took 38% of State funding away from practices over five years were applied disproportionately to general practice leaving it currently unable to take on new commitments without new resources. While hospital budget cuts were less severe, the combination of bed closures, limited manpower and service cuts have also left our hospitals unable to cope with increasing demand. It is a perfect storm for the health service and for patient care. We cannot continue like this. New thinking is needed.

We come from Carlow–Kilkenny where we have had new thinking. We are used to it. There is a 20-year history of engagement between GPs and hospitals, much involving the ICGP-St Luke’s liaison committee. This led to integrated thinking and improved patient flow in Carlow-Kilkenny. We call it a hospital without walls as GPs have very strong relationships with the hospital and are involved in all levels of service development and governance.

Over recent years, given all the challenges, we recognised the need to work more closely. We formalised and then structured this engagement by scheduling monthly business meetings between GPs, consultants, hospital management, CHO partners, mental health, public health and pharmacy colleagues. These meetings attract 20 to 30 doctors a month. It is a forum that builds relationships, encourages ideas and agrees change. It works through contact, respect, trust and innovation. Everyone may attend and everyone is equal.

The outcomes of this integrated activity in Carlow-Kilkenny has created a culture of GP-hospital-community engagement and has led to many local initiatives that have scaled. Caredoc, one of the earliest GP co-ops, began in 1999. The first acute medical assessment unit in Ireland was opened in 2000, which allows direct GP access. We call it streaming. The first acute paediatric assessment unit with direct GP access was opened in 2002. The first acute gynaecology assessment unit with direct GP access opened in 2005. The first GP-led community intervention team, CIT, which brings hospitals into the home, was formed in 2009. A new surgical assessment unit with direct GP access opened in 2014. Other recent service developments include new services in heart failure in 2014, acute arthritis in 2015 and a GP-led gynaecology clinic led by local GP, Dr. Eluned Lawlor, in 2016. The first purpose-built integrated ambulatory care centre in Ireland using an acute floor was opened fully in 2016, again with direct GP access. The concept of an acute floor with GP streaming is a proven mechanism that reduces admissions, shortens length of stay, and helps keep patients at home and not in emergency departments, EDs, or on outpatient department, OPD, waiting lists.

The Carlow-Kilkenny model has now been adapted as a local integrated care committee, LICC, by the Irish College of General Practitioners, the Ireland East hospital group and the primary care division of the HSE as a mechanism in other areas for local engagement and integration between primary and secondary care. The LICC is a bottom-up approach that is supported from the top. This roll-out is now being supported nationally by the primary care division of the HSE. There are a number of LICCs now active in the Ireland East hospital group, including Loughlinstown, Mullingar and Wexford. The Ireland East hospital group has been hugely supportive of this integration with primary care and it considers alignment with GPs and CHOs as a key strategic priority. The Ireland East hospital group recognises that an important role of effective LICCs in a new health system will be to help shift chronic care incrementally from hospitals to primary care in an agreed manner and with the correct resources to deliver benefits for patients. This will ease the burden on hospitals and reduce the cost to the State by supporting GP-led primary care.

We need to take five steps for success on the journey towards GP-led primary care in Ireland. First, we need a culture change towards more engagement between GPs and hospitals who need to work together locally in partnership with management, hospital and community, as equals in care. This LICC engagement process should be costed and funded by the State. Second, we need to move more care out of hospitals and into the community in an agreed and funded manner. The Primary Care Surgical Association is one successful example. GP-led primary care, working through enhanced primary care teams and supported by secondary care, can provide other models of community-based care. Third, we need to resource and strengthen the infrastructure of general practice by increasing the numbers of GPs, practice nurses and other health care staff to deliver these new packages of care. An end-of-life care package should be among the first. A new GP contract that deals with chronic disease is also critical.

Fourth, we need better flow for patients through the health system. Ambulatory care using an acute floor with GP streaming is the future for acute hospital medicine. Scheduled care, including OPD and day care, needs a 21st century model using a shared EHR, ICT, virtual clinics and new care pathways, but GPs are central to these developments. Fifth, we need the political and legislative certainty of ring-fenced funding to allow transformation of health care over an agreed period. This is critical. Clinician leadership and innovation should be supported locally and allowed to scale where there is success. There will be benefits to the State from efficiencies, savings, confidence and a healthier population and workforce. The transitional funding for development of GP-led primary care should not come from hospital budgets. The eventual funding model for the new State health system should be determined only when we have the correct care and treatment model agreed by all stakeholders and we are clear on the workload and costs.

Regardless of the funding model, general practice needs to be at the heart of the new health system. General practice and GP-led primary care can deliver comprehensive, co-ordinated, quality care that is accessible to patients and close to their homes. In an age of multi-morbidity and medical complexity, only the "generalist" GP can deliver appropriate care to this group of people in a cost efficient manner. However, the role of the generalist GP needs to be standardised. We ask the committee to advocate the Farmleigh principles of GP-led primary care, which I outlined in an earlier submission. They clarify the role. These principles were developed by Professor Tom O’Dowd of Trinity College Dublin in consensus with all stakeholders in 2015, using the TCD Chatham House Group, now known as Tomorrow’s Health. The principles articulate clearly what work is done in general practice and who is accountable. It should be central to any new GP contract and a foundation stone for integrated care with our hospital partners.

Professor Courtney will take over from here.

Professor Garry Courtney:

How do hospitals fit into GP-led primary care? We believe that the role of our hospitals is to support primary care, not the reverse. Our current hospital-centric system delivers excellent specialist care but cannot deliver cost-effective care for the tsunami of chronic disease and multi-morbidity that is strangling our health service. A total of 530,000 people are on waiting lists to see a specialist and up to 500 a day are on trolleys, which highlights the scale of the misalignment between demand and capacity. Clearly, capacity in our hospitals needs urgent attention. New thinking on OPD access is also needed, including better use of ICT and virtual clinics in chronic disease. A great example is the heart failure virtual clinic run by Professor Ken McDonald of St. Vincent's Hospital, which shows an 80% reduction in hospital referrals. We need to work with the clinical programmes, which are excellent examples of collaborative care pathways, developed between HSE, the royal colleges and GPs.

Our national manpower status is perilous, both in general practice and hospitals. Many of our young graduates - both doctors and nurses - are leaving. In secondary care, we are reliant on non-national junior doctors to run our hospitals and, without them, the system would collapse. There is also a shortage of consultants. In general practice, some 28% of GPs are aged over 60 and face retirement. We train only 176 GPs a year, yet require 250 just to stand still, given emigration and retirements. GP training numbers need to be increased by 100 and work must be done on retention of graduates. A total of 90% of GP trainees are female and most do not want full-time positions or practice responsibility until their families are older.

The committee’s plan for a ten-year consensus in health and a decisive shift towards primary care is welcome but there are specific challenges to be overcome. Building effective business relationships between secondary and primary care will be the key to success. In Carlow-Kilkenny, we have a tradition of engagement between GPs, hospital consultants and management, based on dialogue, respect, trust and innovation, which builds an integrated health system that works on solutions. This model can be scaled up with primary care division and State support. The emerging LICC process can improve the interface between primary and secondary and should be extended nationally. Ambulatory care should be supported through an acute floor that integrates horizontally with services in the hospital and vertically with GPs and the community. GP-led primary care, working in partnership with hospitals and community, is the best future of our health system. By working together we are stronger and patient care is enhanced. This is integrated care and this is the Carlow-Kilkenny model.

Róisín Shortall (Dublin North West, Social Democrats)
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I thank the witnesses for their impressive presentation. Reference was made to the importance of direct GP access to different hospital services. How is that different from what is happening in other areas? We are all familiar with constituents contacting us where there is an 18-month waiting list to see a specialist. We refer them back to the GP and get him or her to seek access and to prioritise the case if it is urgent. GPs in the Dublin area feel there is no point in doing that or they try and it does not make any difference. What is different about this model? Are improved resources available through the hospital? What speeds the process up and reduces the waiting lists? How is Carlow-Kilkenny different from other acute hospitals?

Dr. Fawsitt said it is important that we move forward with this model while making sure it is fully planned and costed with buy-in from everybody involved. To what extent has he done that planning work and phasing of the transfer of care? Is a model in place that could be adapted in other areas? Is much information available on costing?

My third questions relates to HSE structures. The committee is concerned that with the six hospitals groups and the nine CHOs, there is a mismatch between those areas and they are not aligned. Is that a factor for Carlow-Kilkenny in terms of boundaries? Is it an issue that GPs may send some of their local patients to a hospital group outside the Ireland east group?

Dr. Ronan Fawsitt:

With regard to the Chairman's third question about the structures of the CHO, there seems to be a misalignment at one level but we work on finding solutions to that. People can be creative. It is not an ideal start that they are not aligned but, at the end of the day, if there is a willingness to work with people, we can work with different CHOs and hospital groups. We can get around that if the relationships are right.

What is different about Carlow-Kilkenny is last night we had our LICC meeting, which was attended by 25 doctors, our manager, pharmacist, mental health psychiatrist, hospital manager and the CHO. We discussed issues such as transport of laboratory samples from a rural practice to the hospital in order that the rural practice can survive, communication, and the increasing number of scopes.

As a group, we came to share a similar view on many issues and on the fact that change was needed in some areas in respect of which we needed to improve. When one gets people in a room and breaks bread with them, one begins to trust, get ideas and scale solutions. That is what we have done over a number of years. There is no magic to it; it is about getting people together who have a shared vision and who make things happen. The projects that we mentioned in the submission are real, tangible and actually happening. When one sees a product like that year after year, one begins to realise that this process works. If I was looking forward, I would say that we need to develop those kinds of relationships everywhere in Ireland and that every acute hospital and CHO should be involved in this. It is already supported by the college.

The third point is about planning and costing. We are not health economists but what we have done is change things incrementally. We have come from a situation in which we had beds in corridors 20 years ago. We had admissions rights to the hospital and we used to admit our patients to the hospital corridor, which was not good. We sat down and asked, "Look, how do we fix this?". The idea of the acute medical assessment unit came up, again, from contact, trust and time. The costing model comes when one gets the work right. Once we have a sense of the right way to flow the work, it is then a job for a health economist.

I believe that people should have access to health care as a fundamental right. There is no question about that and I think we are all agreed on it.

Professor Garry Courtney:

I wish to add to the comments about funding. Ours is the 11th busiest hospital in the State and we have the 18th largest funding. Therefore, we are relatively underfunded. As a result of that, we work differently. If a GP in north Dublin sends a patient to the emergency department, ED, the his or her letter is ignored. Why would a patient in north Dublin go to see a GP? It does not do them any good. If a GP in Carlow or Kilkenny sees a patient and writes a letter, the patient goes to the top of the queue. The patient is registered in the ED - we call it an acute floor now - and goes straight to where the GP asked him or her to go. There is no middleman, no nurse triage and no quick look by an experienced ED doctor. The patient goes straight to where the GP asked him or her to go. If the GP wants the patient to receive medicine, he or she goes to the acute medical assessment unit. If the GP wants the patient to go to psychiatry, he or she goes to acute psychiatry assessment. If the GP wants the patient to go to paediatrics, he or she goes to paediatrics. It is not always right, but there is an astonishingly low number of errors occurring, perhaps one per week. We have 45,000 ED attendances per year, which is almost the same as St. Vincent's Hospital. The GP has absolute primacy.

Róisín Shortall (Dublin North West, Social Democrats)
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I thank the witnesses. I invite members to contribute in groups of three. We will bank the questions and deal with them in that way.

Hildegarde Naughton (Galway West, Fine Gael)
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I thank the witnesses for their presentation. Dr. Fawsitt referred to evidence-based clinical algorithms. I wonder if he could expand on that, on how patients are identified as being suitable for discharge and on how that works within the system. Does he have any figures on how many inpatient bed days this care model has saved? That would be very helpful. He said that the hospital managed the completion of IV antibiotics in order that patients can be discharged early. Is it feasible for IVs to be administered out outside of hospitals in the first instance? I make particular reference to nursing homes and that provision. Has that been explored or has any work been done in that area? The same applies to PEG tubing, catheters, etc. What type of hospital admissions has this service avoided? Does the witness have any figures on that? On the more ambitious term "hospital in the home", could one of our guests expand on what this would entail? It goes back to the community by reducing the number of people entering the hospital setting. I would be very interested in hearing more about the term "hospital in the home".

John Brassil (Kerry, Fianna Fail)
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I thank the witnesses for their presentation. For many years, I have heard of the Carlow-Kilkenny model. I am glad it is not an urban myth and that it actually exists. For the committee's work, as the sessions go on, it is becoming clearer that, in the context of a ten-year strategy, we need to start at primary care and get it right. If we fund it, resource it and replicate the model at St. Luke's Hospital, it will then have effects that will provide solutions more quickly further down the line. That is certainly something that is becoming very clear. I hope that is where we will be starting in our conclusions.

I have a few specific questions. A group from Dublin appeared before the committee earlier. Its members are GPs who are very under-resourced and based in deprived areas. How difficult was it for the witnesses to roll out this programme? They started out 20 years ago, I think they said. No matter what area one is in, there is resistance to change. People do not like change. Regardless of what profession one is in, change is almost automatically resisted. What level of resistance did the witnesses experience and how did they overcome it? More specifically, if the witnesses were to look at their model and replicate it throughout the country, how long would it take to put in place? I would hope that a 12 to 24-month target could be set and achieved. Perhaps it is hypothetical, but I hope it is not. I hope that, with the right attitude and determination, it can be achieved. That is what I would like to hear our guests' opinions on. The St. Luke's Hospital model does not only deal with the primary care, it has also expanded into the hospital. The link between the GP and the ED and how St. Luke's Hospital has managed to streamline it is where the future is. As I might have said at the start, the solution might be staring us in the face. It is just a matter of grasping the nettle and taking it up.

Michael Harty (Clare, Independent)
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I thank Dr. Fawsitt and Professor Courtney for coming before the committee. As Deputy Brassil said, the Carlow-Kilkenny model has been whispered about for years. Unfortunately, it is not being adopted by other hospitals. The first question I have relates to transitional funding. Could the witnesses explain it and how it is used to change from the old system to the new system?

My second question is about how the witnesses got started on the system. I think they are very lucky in Carlow and Kilkenny. I believe in people being in the right place in the right time. The two witnesses, all of their colleagues and the management structure of St. Luke's Hospital have come together with new thinking quite uniquely, having been in the right place at the right time. It is difficult to fit that new thinking into an old-style model. Our old-style model of GP-hospital interface is disjointed and disconnected. What St. Luke's Hospital has is the opposite. How does one convince those operating the old-style model to transition to the new? We had that difficulty in the mid-west in that just this week we have had the last connection between our GPs and our local hospital broken. We now cannot communicate with our hospital anymore. We have to go through an anonymous bed bureau located in the regional hospital in Limerick. The work that was built up over the past three years in Ennis is now gone in one fell swoop. How does one get to people to get them to change their thinking?

My final point is that this should be a necessity. In all hospital groups, this model should be a necessity rather than an option. That is the message we need to communicate.

Róisín Shortall (Dublin North West, Social Democrats)
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The Deputies asked many questions. I invite the witnesses to respond to them.

Dr. Ronan Fawsitt:

Deputy Hildegarde Naughten asked for evidence. While I am not an evidence person, I know the acute medicine programme Professor Courtney started in Carlow-Kilkenny reduced average length of stay in the hospital by 1.6 days within five years. That is the equivalent of generating 750 beds in the system and this has been documented.

As regards the community intervention teams, CITs, these are music to my ears. General practitioners need to be involved in the community, providing more services, and community intervention teams are an ideal way of doing so. The process is currently nurse driven. I would like it to be led by general practitioners but this requires GP-led primary care. In fairness, the Ireland east hospital group is looking at a process in Navan under which general practitioners would visit patients' homes as part of the community intervention team, put up the intravenous drips and monitor the patient with pneumonia over a weekend or whatever. The GP would do the extra visits.

As a general practitioner, I may see 40 people per day. Yesterday, for example, I saw 46 people face to face, including two home visits and two visits to nursing homes. If I receive a call in the middle of the day informing me that Johnny is very sick, I cannot make a home visit, even if his house is just down the street, because I do not have the capacity to be in two places at one time. However, if a general practitioner led CIT service was available and I was aware that Johnny had chronic obstructive pulmonary disease, CPOD, and needed IV antibiotics, oxygen and so forth, I could call the CIT service because I would know the colleague in the service would be a doctor rather than a nurse. While a nurse-led process is sometimes fine, in cases where clinical judgment is required, general practitioners must be involved. This is where GP led primary care can drive change.

The funding must follow the patient. The previous Minister often spoke of money following the patient. The money should follow the patient through the community intervention team process because it makes sense. General practitioners are trained and are like powerful thoroughbred horses. However, we do a great deal of plough-sharing when we could do much more if we had more resources. We want to do more and community intervention teams are an example of shifting care into the community to avoid people ending up in Professor Courtney's hospital or on trolleys in Beaumont or Our Lady of Lourdes hospitals. We must keep frail elderly people out of hospital using new care pathways. However, new care pathways cannot be agreed if there is no contact. I am taken by Deputy Harty's comment that he does not have a pathway for discussing clinical issues with his colleagues in Ennis, Limerick or Clare. It is for this reason that we need this type of process for engagement.

Deputy Naughten asked what evidence is available on our pathway in respect of admissions. We opened an acute surgical assessment unit, ASU, two years ago. The liaison committee discussed this issue in great detail over a number of years and we were pushing for such a unit. Within one year, the number of admissions for acute surgery declined from 4,500 to 2,500 because a senior decision maker in the community, namely, the general practitioner, now refers directly to a senior decision maker in the hospital, namely, the surgeon, and the patient is seen within one hour. If, for example, a patient has a problem with his or her appendix, he or she is seen by the surgeon and either admitted, operated and sent home or, where the case is not acute, he or she will be seen and sent home on the day. This process reduced the number of admissions by 2,000 in one year. It creates the efficiencies that would generate funding to drive the process of extending other services into primary care. If we make funding savings through this process, they should be reinvested in primary care to drive another project or to scale a project. If, for example, we have a successful community intervention team project, it should scale to Deputy Harty's patients as well.

Professor Garry Courtney:

I am from west Tyrone in Northern Ireland. When we meet, we leave our weapons outside, as it were, and talk about absolutely everything. We totally respect and value our general practitioner colleagues who are completely disrespected and ignored in many parts of the country. I see medical students who will present a case to me in the outpatients department without referring to the general practitioner by name or even to the letter the GP has written. I pull them up on that. There is a culture in place whereby medics do not know what the GP does and do not view it as important in any case.

Róisín Shortall (Dublin North West, Social Democrats)
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It is not unrelated to recruitment problems.

Professor Garry Courtney:

That is true. The acute hospital system is completely outdated. It was designed perfectly for a very small number of hospital consultants. When I went to Kilkenny Hospital, there were two physicians, no paediatricians and one radiologist. These are ridiculously low numbers and a system had to be built around the consultants because there were so few of them. The hospital now has 11 physicians, four radiologists and six paediatricians. There has been a major investment in the hospital system and taxpayers have stumped up for many improvements. Once a patient is inside the front door and before he or she reaches discharge, the Irish hospital system is extremely good. It does some things terribly badly, however, for example, management of chronic diseases, which should be dealt with by general practitioners in the community. People with chronic diseases should not even get into hospital and instead should be dealt with and paid for by GPs.

We were asked a specific question. The Health Service Executive has funded diabetes nurse specialists who work between the hospital and community. It also funded chronic obstructive pulmonary disease, COPD, nurse specialists, heart failure nurse specialists and physiotherapists to run pulmonary rehabilitation clinics. General practitioners have access to this service and we have opened the hospital to GP referral for echocardiography, certain extensive tests known as BNPs or B natriuretic peptide tests and all of them have full access to ultrasound.

Cultural change is needed and it must involve transferring a substantial amount of work to general practice. This must also be paid for. What hospitals should do in future is the high-tech work such as kidney transplants, an area in which this country is world-beating, technological medicine and the 5% of chronic disease that general practitioners cannot manage on their own. I would love to get to that position in two years. In that respect, God bless the Deputy's optimism but it took us a long time.

John Brassil (Kerry, Fianna Fail)
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There is no point in targeting something one cannot achieve. What would be a reasonable timeframe?

Dr. Ronan Fawsitt:

Deputy Brassil's question is apt. To respond to the question on how we will manage change, we must involve everybody and everybody must be at the table. This means creating the table and resourcing it. We have done this pro bonofor years but if it is to scale nationally, the State must invest in integrated care and integrated care committees. The amount of money required is very small but it would deliver significant change. This is a strategic issue which the committee could recognise.

As regards rolling out local integrated care committees, LICCs, nationally, this could be done very quickly. It should be recalled that LICCs have the support of the Irish College of General Practitioners, the primary care division and one of the hospital groups and there is no reason they could not expand further. What is needed is a decisive political push and a small amount of resources. I believe the LICC process could be fully engaged within 18 months and two years at the outside. There is no reason we could not achieve that. I speak to general practitioners the length and breadth of the country and they want to engage almost to a man or woman.

As Deputy Harty correctly stated, people want a forum to engage with their consultant colleagues. They do not regard their colleagues or management as enemies. However, they do not have any mechanism for engaging, which leads to frustration and arguments. We no longer fight, although we disagree and have robust disagreements, including last night when we disagreed on communication. However, we left the meeting as colleagues and friends, having thought about how we will fix the matter. The issue is one of culture but one also needs a structure. The 25 people in the room last night were disenfranchised medics from across counties Carlow and Kilkenny who are not getting anything done and are becoming peed off with everybody. The State must invest in this process.

Róisín Shortall (Dublin North West, Social Democrats)
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Apart from medics, who else attended the meeting?

Dr. Ronan Fawsitt:

It was attended by the hospital manager, the community health care organisation senior management in primary care, two hospital pharmacists, a senior consultant psychiatrist representing mental health and a number of general practitioners from Carlow and Kilkenny, including some who had travelled 30 miles to attend.

Professor Garry Courtney:

The meeting was held at 6.30 p.m. after a long day's work and people attended pro bonobecause the purpose of the meeting was to arrange dialogue with the hospital to benefit their patients. They brought some particular problems to our attention which we will address immediately. The management of our hospital is extremely concerned with primary care, which is highly unusual in the hospital service here.

Dr. Ronan Fawsitt:

Deputy Michael Harty asked a question about transitional funding. I was at a talk by Mr. Paul Grundy at the weekend on the issue. The key is resources and to move the food. How does one handle stray cats? The answer is one moves the food. One has to incentivise consultations that are complex in primary care and general practice. One must incentivise activity, outcomes and quality. One must move the food. The Oireachtas health committee could lay down a marker new thinking and ascertaining how to change.

How do we get a group of people together? There is nothing like sitting down at a committee meeting and listening to people. That is what we do and what an LICC process would do. One brings ideas, enthusiasm and passion to the table, thus effecting change. It is called peer pressure and seeing the "light of day". It is also driven by data. When we attend these meetings, the hospital manager may have figures and the consultants are present to state the length of the waiting list. That is how it happens. It is a very powerful process and as simple as soap. There is no magic to it.

Michael Harty (Clare, Independent)
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Is there a trolley problem in Kilkenny?

Professor Garry Courtney:

Yes. In the past three years there has been an increase of approximately 30% in emergency department attendances. The famous day on which we had 27 beds in the corridor was in 1999. I actually felt we were losing control of the hospital. We went to the Lord Bagenal Inn in Leighlinbridge and met many general practitioners and agreed with them that they should give up their direct admission rights to beds in the corridor and that we should set up the acute medical assessment unit. For the following six or seven years, we abolished all beds in the corridor. That was wonderful, but then the recession hit and we closed 40 beds in the hospital. There was a reduction in the number of beds from 300 to 260. We closed 80 beds in the community. Therefore, we took 120 beds out of the system at the same time as we were ramping up services for care of the elderly, chronic disease care services, etc. An acute ward floor has been opened and it has exposed a little of what one might call health tourism. In Nenagh hospital, in the Deputy's area, we are seeing patients from Borrisoleigh, Templemore and Templetuohy, which is unusual. We are seeing patients from Ballylinan, Abbeyleix and Durrow and also from places down towards Clonmel and up towards Portlaoise. We are exposing a capacity problem, but the way to deal with it is to ensure one cannot say "capacity problem" without having data to back it up. I do not like to hear people saying we need 200 beds. Rather, I want them to give evidence that we need beds for stroke or stroke rehabilitation patients, but they will be provided in the community. I want them to give evidence that we really are short of intensive care unit beds and probably need some, or that we need beds in the acute medical assessment unit. However, to make a blanket statement that we need beds is not sufficient. It costs €500,000 to provide a bed and the necessary staff. I believe between 500 and 1,000 beds have been provided with the necessary staff in acute hospitals with patients that general practitioners should be looking after in the community. It would take ten years to provide 1,000 beds and we do not have the money to provide them in any case. If we did, we would not have the necessary staff. Why not discharge between 500 and 1,000 patients to general practitioners who are very willing and able to look after them? We should fill the freed-up beds with patients who are being treated in the corridor on trolleys.

Dr. Ronan Fawsitt:

We have a unique opportunity in Ireland. In America the health budget has gone crazy. For the past 100 years the health authorities have been focusing on hospitals and very little on primary care services. They are, however, beginning to move back because they see the value of primary care services. In Ireland we have a trusted cohort of health practitioners called general practitioners who are the most trusted group. We literally provide care from the womb to the tomb. We mind the front and back doors of every acute hospital in the country and could do so even better if we had a little more help. There are 22 million face-to-face consultations each year on 3% of the budget. If we had more of the budget and if it were delivered in a meaningful way and directed towards projects that made sense such as the community intervention team project and having an enhanced primary care team, there would be a real benefit. Primary care teams are not working and primary care centres are largely empty. It is a pity, but there has been no engagement between clinicians, primary care teams and others for a number of years, as the Deputy knows. In a heartbeat that could change. We need to focus on primary care teams and primary care centres, but the model needs clinical leadership. There has been an absence of clinical leadership in the primary care model as constructed. Leadership requires some resources, support and assistance. Having GP-led primary care services is the future of the health service. A health service that does not have general practitioners at its heart will not succeed.

Róisín Shortall (Dublin North West, Social Democrats)
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When Dr. Fawsitt refers to GP-led primary care services, is he talking about the model in which allied health professionals would be employed as public sector workers?

Professor Garry Courtney:

It would have to be a multidisciplinary approach.

Róisín Shortall (Dublin North West, Social Democrats)
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Sometimes those who talk about GP-led primary care serices talk about the general practitioner employing people. Is that the model about which the delegation is talking?

Dr. Ronan Fawsitt:

Again, that would be a matter for negotiation. We really do need a GP contract as a matter of urgency to ensure clarity. What I am talking about is a GP-led team of fellow professionals who share the task of providing care in a meaningful way over time. If I wanted to open a new stroke unit in St. Luke's hospital in the morning - we have one and it is probably one of the best in the country - I would go to one of the senior clinicians to ask how I should proceed. I would then bring in the manager and, using the evidence and funds available, ask what we could do. I would then do what I could. There has been no such enthusiasm in the area of primary care. We are the experts on what the clinical pathways should be. Where there are not enough clinical pathways, we can discuss the approach to take with our colleagues as part of a bigger team.

Having GP-led primary care services is not just about the clinical pathways but also about the care pathways. It is about joined-up thinking. If we were to develop a health service in the morning, would we pick an airline model? I would because everybody would be equal. If one piece of the puzzle were to fall, the whole thing would fall down. The pilot is not the most important person in the airline; the passenger is. We really need to focus on the patient's journey.

Kate O'Connell (Dublin Bay South, Fine Gael)
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I welcome the delegates and thank them for attending. I had the pleasure of being welcomed by them in Carlow–Kilkenny a few months ago and was very impressed.

I wish to refer to a few issues, including the structure of the HSE, the regional health organisations and the separate social and mental health care services. In Carlow–Kilkenny has this issue been addressed in the model? Do the delegates have a mechanism by which those involved on the social care side, in psychiatry and mental health services feed into their system? Has their model addressed what I would regard as the lack of integration within the structural part of the HSE?

My next point follows on from the discussion with the previous delegation. In the experience of the delegates, do they compete with the acute services in the hospital in terms of access to diagnostics in Carlow–Kilkenny? Are they fighting for space and, if so, how does it work out for them? Have they suggestions as to how to improve the position in this regard?

In the previous session we spoke about the deprivation index. When the delegates are following the care pathway for a patient through this system, are there loss leaders, a term used in retail? Are there patients with very complex conditions who follow the same pathway as others but whose care is not being funded adequately? Is this at the expense of somebody else? How are the cases of patients who require particularly complex care managed? Does it work out in Carlow-Kilkenny?

On the social and mental health care aspect of the health service, do the delegates have very good relationships with public health nurses? Is there a maternity service in Carlow-Kilkenny?

I presume that is the case. How do maternity services work there when it comes to public health nurses dealing with a woman once she has had her child? Does it have a domino scheme similar to the one at Holles Street where maternity care is midwife-led?

Reference was made to GP-led primary care. Why would it only be GPs? Do the witnesses mean GPs being at the head of it and somewhere below that community pharmacists and others being involved? How do they envisage community pharmacists, public health nurses and people working in the community fitting into the structure? I know that the approach is completely fragmented and that a great deal of time is spent on the telephone to people. There is also the issue of the errors that can occur during a telephone call and the number of fax messages that are sent. People in other organisations do not use fax machines as much as doctors, pharmacists and agency personnel. They laugh when one mentions a fax. How do we get around the cultural issues that were referenced? How do we make everybody in the system feel important, loved and appreciated?

Josepha Madigan (Dublin Rathdown, Fine Gael)
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Lawyers receive many faxes as well. I thank the Professor Courtney and Dr. Fawsitt-----

Róisín Shortall (Dublin North West, Social Democrats)
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A mobile phone is causing interference.

Josepha Madigan (Dublin Rathdown, Fine Gael)
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-----for their presentation, which was very interesting and comprehensive . Their answers to the questions have clarified many questions I had intended to pose.

From a broader general perspective, I am interested in the Carlow-Kilkenny model. There is much to recommend it.Vis-à-vis the rural-urban divide and in general terms, would our guests foresee see any difficulty in facilitating that model in an urban environment as opposed to in a rural one? I know the eye cannot behold itself but, from a reflective perspective, do they envisage any particular difficulties in an urban environment that they would not see, for example, in Carlow-Kilkenny and, if so, how could we address those? That will be important in terms of, as was mentioned, rolling out the model nationwide. Those are my general points.

Róisín Shortall (Dublin North West, Social Democrats)
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That is a very good question. I call Deputy Louise O'Reilly.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I have two brief questions. Reference was made to the 5% of patients who require chronic disease management that GPs cannot offer and who would ideally be managed in a hospital with high-tech equipment where complex work is performed. Do the witnesses know or are data available on the level of chronic disease management taking place inappropriately, as they might say but possibly because there is no other choice, in the acute hospital setting that could be taking place in the community?

My second question relates to the use of diagnostics in the community. A group appeared before the committee just prior to our guests and its members informed us that they had diagnostics - specifically radiography - in the community and that the machines were not used. There was not sufficient critical mass to facilitate them being brought into use. I am not referring to the massive machines but to what extent could some diagnostics be carried out in the community, thereby avoiding the need for people to go to hospital? I would like to hear about the witnesses' experience. I was disappointed to learn that the machine that in the community setting was not being used. The delay in accessing diagnostics results is a particular problem and it is one that has been raised with us. I would have assumed the easy solution would be to locate diagnostics equipment in a community setting thereby removing it from the over-involved systems in hospitals. The latter could then focus on carrying out the more high-tech work. I would just be interested to hear our guests' views on that.

Róisín Shortall (Dublin North West, Social Democrats)
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Dr. Fawsitt and Professor Courtney might address those points.

Dr. Ronan Fawsitt:

I thank Deputy O'Reilly for those questions. On the diagnostics issue, if we centralise diagnostics in a primary care centre and very few GPs have access to it, the pathway will shut down and it will not get traction. We have proposed that existing primary care centres and the new 80 or so that are being built should become primary care resource centres. Such a centre might not necessarily have a GP in the room or in the building but all GPs in the relevant area would refer their ultrasounds, echoes, etc., through that centre, thereby creating traction. Believe me, the machine at the centre in question would then be used. Why would I send my patients to Professor Courtney for an ultrasound when I can get it done quicker at a primary care resource centre down the road? Probably the same radiologist would read it because we will have to enter into contracted arrangements for high-quality radiology services with the relevant professionals. This is what is known as joined-up thinking. Having primary care resources centres is a way of maximising usage of primary care centres.

There will always be that 5% of patients requiring chronic disease management. I do not generally look after insulin-dependent diabetics because they need something more than me. In Carlow-Kilkenny we fit more pumps for children than anywhere else nationally. We have no waiting list for new diabetics in Carlow-Kilkenny because the service is run by clinical nurse specialists in co-operation with the GPs. If I need a person who has been newly diagnosed with diabetes to see a consultant, that will happen. If we put the care and resources in the right place, we will free up the hospitals.

Róisín Shortall (Dublin North West, Social Democrats)
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Is there an estimate of the level of chronic disease management that is currently taking place in hospitals? What is the split between hospitals and the community setting?

Professor Garry Courtney:

I can only speak about our hospital. I do not have an estimate for that. We have a very forward-looking endocrinologist in our hospital who looks outside the hospital and almost all diabetic care is delivered in the community, so that is close to the 5% figure that was mentioned. He only sees new diabetics, GPs follow up on them and we have diabetic nurses that work across the hospital and the community. Chronic obstructive pulmonary disease, COPD, is the next biggest disaster for the health service and we are managing patients with that condition with nurses employed by the hospital who work in the community. I would love to provide pulmonary rehabilitation in the community but because we do not have the space, we do that in the hospital. Hospital doctors do not see those patients, they are seen by a physiotherapist and a nurse. We treat patients with heart failure through virtual care in a linkage between GPs and Professor Ken McDonald at St. Vincent's Hospital. Kilkenny is a bad example to use in this respect because we push the care of all those chronic disease cases out into the community. If I had to guess - and it is a guess - we probably treat 75% of cases in the community, which is fantastic. The figure for the remainder of the country might be 50% or less.

I will tell the committee something that I find maddening. GPs in our hospital are allowed total access to blood tests, BNP tests, and ultrasound results. At our meeting last night we discussed the inclusion of echoes. The HSE is catching on and it will now allow GPs to purchase ultrasounds and they will pay for them. However, our hospital has been bearing that cost. We are delighted about this. We have done a study and it shows that a GP who has been qualified for 20 years knows more about ordering an ultrasound than a junior doctor who has only been qualified for 20 months. There is a perverse incentive there. The hospitals that do not allow GPs ultrasound access will be paid for that and my hospital, which has been allowing GPs such access for years, does not get paid. That is annoying.

Dr. Ronan Fawsitt:

To answer Deputy Madigan's question on the urban-rural divide, getting GPs to engage and getting everybody around the table is more challenging in urban areas, particularly in model 4 hospitals where a GP in north Dublin might be referring patients to two or three hospitals. What unifies them is the Irish College of General Practitioners and it has faculties. If we aligned the faculties with the hospitals, there would be a link. It is about connections. There is a solution but each area would be different. Our model might not translate fully to Wexford, Mullingar or Clare but parts of it will. It is the principle of the contact. Every area is different and they will come up with different solutions but this is the way forward.

I thank Deputy O'Connell for her questions. She asked about mental health, social care and psychiatry and we have that group at the table. They come to our liaison meeting. They attended the meeting last night. We have big issues with the child and adolescent mental health services, CAMHS. That group has also come to the table. It is more difficult to get those involved in providing those services to continue with the process. They have not continued with the process as fully as the other groups. Our strength is that everybody is at the table and if we need to bring somebody else in they will oblige. It is like this committee. If the Chairman invites somebody to attend, he or she will probably come because he or she will want to know what is happening.

Everybody is at the table. We are competing as regards access to diagnostics. We had a discussion about echoes last night. We want more echoes to be done at St. Luke's. Professor Courtney is running an excellent and huge oncology service at a new centre in St. Luke's. Cancer patients who are on certain treatments need seven echoes. Elderly and frail patients will die if they do not get the right medicine. They need echoes if they are to get the right medicine. We have had a number of robust discussions. It is not that there is not a willingness - it is that the resources are not available in the hospital system to give us what we need in the community. That is why we need to shift to more GP-led primary care. My colleague., Professor Courtney, might answer the question about complex patients.

Professor Garry Courtney:

I thought it was a great question. Deputy O'Connell was talking about magnet hospitals. I love that phrase, which is used in the US. Many hospitals in the US are closing because of chronic care. Dr. Fawsitt has mentioned the disaster in terms of funding. Some hospitals in the US have said "We are not in the diabetes business any more" and used that as a means of getting rid of diabetes patients, many of whom are black and poor, are losing their legs and are in need of dialysis or surgery. Patients can become costly when they are badly managed at the beginning. We need to stop those patients becoming complex in the first instance. This must involve GPs treating them correctly.

Junior doctors love working and training with the very small number of complex patients who present at our hospital. We have a three-year waiting list for specialist registrars to come to our hospital. We have low number of locums. By taking on complex patients and moving chronic care to the community, we attract many junior doctors and we spend less on locums. Complex care is quite expensive, but a hospital that does not offer complex care is not an acute hospital. We have to do it. We think we have achieved good outcomes. We need to go to outcome-based management and activity-based funding. We are saving a great deal of money.

I am very interested in the concept of magnet hospitals. A study in America examined why hospitals were closing. It was found that people were not coming to work in certain hospitals even though they were being offered 20 types of flavoured ice cream, running tracks on the roof and free access to health gyms. The simplest outcome of the study was that doctors and nurses want to work in hospitals where they feel valued and are allowed to do their jobs. People do not feel valued in our hospital system at present. We cannot get at the patients to do our jobs because of the chaos at the front door of emergency departments, as Dr. Fawsitt has put it. At Beaumont Hospital, there might be five trolleys bounced up against each other and a guy against the wall who is not being seen. Nobody wants to work in such a system. Nurses and doctors are fleeing the country.

The acute floor would work in an urban environment as well. The deprivation index, which was mentioned by Deputy O'Connell, is much higher in Limerick and north Dublin than in Carlow-Kilkenny. There is no denying that there is a relatively affluent population in Carlow-Kilkenny. Two thirds of the people in Carlow-Kilkenny live in rural areas. Kilkenny is quite a small urban area. The way we get around the urban-rural split is that all the GPs come to the local integration committee. I would say we have a disproportionate representation of rural GPs because they want to get into Kilkenny to talk to the hospitals. That answers the question about the attractiveness of complex care.

We do not have a domino service. We would like a domino service. I think that is the future. Women who are delivering should be allowed to deliver in line with the Holles Street domino model, which is very good. We do not have that model. I would like to have it. Not having it is a big gap in our system.

Dr. Ronan Fawsitt:

We have a GP-led gynaecology clinic. We are changing the culture slowly.

Deputy O'Connell also asked about community pharmacists. Community pharmacists keep me out of the High Court day and night. I get many phone calls, but I will always take calls from community pharmacists because I value them. We need to improve our links with community pharmacists and work with them. We need to stop treating them as enemies. They are our colleagues and they help us. Last year, we started to involve them in a liaison process. We have not continued that to the extent that we would like. From that process, we developed in the hospital a medicines management process involving community pharmacists, hospital pharmacists and GPs, with the aim of improving the quality of discharge prescribing. We got funding from the Ireland East Hospitals Group. We evaluated that process after a year.

HIQA now sets standards of care for hospital prescribing, discharge prescribing and complex care. In a single year, we went from meeting 40% of HIQA's targets to meeting 100% of its targets. We believe the quality of this expensive and costly process keeps readmissions down. We cannot prove that yet because we have just started the process. We are working with community pharmacists, hospitals and GPs to improve the process as we go along. I would love to see the day when community pharmacists will be involved in the local integrated care committee process. That day should not be too far off. It will take time for this to happen, but it should not take too much time because it is sensible.

Billy Kelleher (Cork North Central, Fianna Fail)
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When I had the pleasure of visiting St. Luke's Hospital some time ago, I got first-hand experience of what is being achieved there as opposed to what is trying to be achieved. Many issues have been raised today and questions on them have been answered. Given that the model being developed and expanded by Dr. Fawsitt and Professor Courtney and their colleagues is successful - I refer to integrated systems, streaming of patients and patient flow, management in the communities and good links between GPs, hospitals and other allied health professionals - it is amazing that it has not caught on across the rest of the health service. I suppose we should try to see where this successful model can be used. Most people have referred to it in various committees over the years, before we ever decided to have a ten-year health strategy. It has been held up as a flagship, but flagships should be beacons and we should all be trying to get where we are.

What is the nature of the institutional resistance at management and professional levels? I assume there is resistance within the various clinical professions that are there. What walls were put in front of Dr. Fawsitt and Professor Courtney, or between them, at the embryonic stages of the development of this model? Are those walls still present in the broader health system? What can we do to ensure we try to break them down? Even though we aspire in our primary care strategy and our individual deliberations to everything Dr. Fawsitt and Professor Courtney have said here today, we continually seem to be shovelling money into acute hospital settings as part of a fire brigade-type effort, while at the same time squeezing the life out of primary care to make sure more people end up in the acute hospital setting. The eternal cycle goes on. I would like the witnesses to expand on the institutional issues.

The GP contract is coming up for negotiation. Reference has been made to chronic disease and illness. It has been suggested that diabetes should be managed in home care and in the community base. Similarly, chronic obstructive pulmonary disease and many other chronic diseases and illnesses could be managed in the community. I sometimes wonder whether we use our nurses and nurse specialists effectively across the health services. Do the witnesses think enough emphasis is placed on nurse-led programmes in the community under the guise of the GPs in that area?

We have raised the issue of diagnostics on numerous occasions. Every GP tells us that access to diagnostics is a problem. Dr. Fawsitt and Professor Courtney said in their submission that access to diagnostics should be independent of hospitals. If we did not organise the system in that way, the emergency departments of hospitals would be full of people who come through the front door. That setting always takes precedence in terms of capacity. What do the witnesses mean when they say that diagnostics should be independent of hospitals? Do they mean that they should be physically independent, or that they should be based in regional primary care or urgent care centres? What do they mean when they use the word "independent" in this context? Who would be managing them?

Joan Collins (Dublin South Central, Independent)
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A number of the questions I had intended to ask have already been posed, so I will not repeat them. I will be interested to hear the witnesses' response to the points raised by Deputy Kelleher. It is obvious that there had to be a change in culture. Dr. Fawsitt spoke about moving the food to deal with stray cats. Smokers can try and try again to give up cigarettes, but that will not happen until something clicks in their heads and they realise it is time to stop. When that happens, it is easier to quit than people might think. I hope those present understand the point I am making. Why has this thinking not spread to other regional hospital areas? Why are people not thinking about how to adapt something that actually works to their own communities? I think this could be the biggest issue we face as a committee. If we are to recommend that this type of model should be used, we will have to look at how we develop it.

There is a point about reinvestment in that it will not go into a black hole, but how do we put protocols in place to ensure that will happen? The matter must be discussed with the Health Service Executive and the integrated care committees.

I live on the north side of Dublin and the father of my GP assisted my mother in giving birth to all of us at home. That man's son took over the GP practice and knows all of the family inside out. He knows our history and whether we are sporty or were healthy when we were young. It makes sense that experience feeds in for people who are chronically ill and need assistance. When an ill person presents at a hospital, he or she is very much dealt with as is; he or she will be put into an acute bed or face surgery. As Deputy John Brassil stated, the model we are discussing could be key in addressing the longer term ten or 15-year strategy for hospitals. I support it and wish to examine it in further detail.

Dr. Fawsitt has stated 28% of GPs are over the age of 60 years, while 33% are over 55. Within five or ten years we will lose a significant number of experienced GPs. That again raises the question we discussed at the last meeting of how we keep the GPs that are being trained in the system. That will be crucial. We should recommend that this be done with GPs, nurses and other doctors.

Michael Harty (Clare, Independent)
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Continuity of care is a major issue and GPs are ideally placed to provide for it. With geriatricians, they are probably the last of the generalists practising medicine in Ireland because as it has developed, it has become overspecialised. There are nephrologists, neurologists, respiratory physicians, diabeticians and endocrinologists and they all look at what is happening in their own fields. A person with several diseases will go to this or that clinic, but we are left to decipher what has happened in all clinics. Quite often we say to patients not to have a prescription filled until they see us first, as the drugs prescribed by a particular consultant may not be compatible with the others being used by them. Continuity of care and being a generalist are extremely important in general practice which we must preserve and develop.

The service in Kilkenny is an exception, but in the other hospital groups we are losing the connection between the GP and the hospital, which is so vital. I once asked an endocrinologist at a meeting why he kept bringing back all of the well controlled diabetics every six months as I did not see the point. He argued that diabetes was a lifelong condition and that the people in question could not be discharged. That is the mindset we must try to break down. As a hospital doctor, the easiest thing to do is what everybody else did in the past, with the result that the process becomes self-perpetuating. We need to get hospital consultants to look up to see what is happening, as what is happening cannot work. Deputy Billy Kelleher asked the question, but I am very interested in the answer. Where is the resistance when it is crystal clear that what is happening is not working?

Professor Garry Courtney:

We are protected.

Dr. Ronan Fawsitt:

May we name names?

Róisín Shortall (Dublin North West, Social Democrats)
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No, most definitely not.

Dr. Ronan Fawsitt:

May we tell you the real deal?

Professor Garry Courtney:

Deputy Billy Kelleher walked through the hospital and saw the patients. Woodrow Wilson said that if one wished to make enemies, one should try changing something. I have written down the term "overspecialism". We have the best doctors in the world. For example, renal doctors want to provide the best care for their kidney patients, while diabetes doctors want to provide the best care for patients with diabetes. However, they do not talk to each other such that if a patient gets something, it is off that doctor's plate. There is incredible competition among overspecialists.

To be fair, I am the lead in the acute medicine programme and there are 33 acute hospitals in the State, 32 of which have acute medical assessment units. The 33rd in Portlaoise is due to open. We had a communication the other day about a local hospital that was withdrawing care services. I will deal with that matter. Acute medicine and the generalism the committee wants are hard and risky because doctors forget their training. They can be very busy and work very hard, as do GPs. Even if a consultant wants to meet and talk to GPs and do what is best for the patient, the nurses must also be involved, with the physiotherapists and the manager. There are unions everywhere.

Some time ago we were brought to Farmleigh when Mary Harney was Minister for Health and Children. We met the leaders of the unions, including Mr. David Begg, Mr. Peter McLoone and Mr. Liam Doran, and told them what we wanted to do. The manager was present, with Dr. Fawsitt and the director of nursing, and everybody listened very carefully. However, the leaders told us that we were living in a bubble in Carlow-Kilkenny and that they would not disrupt it as it was working grand. They said there were too many moving pieces to be linked. This is where I think the GP local integrated care committee works. It is the only time a nephrologist, a diabetes doctor and a lung, heart and liver doctor might sit down together. There is the realisation that if we do not work together, we are just fighting with each other. I have noticed that at a medical board meeting the consultants may be aggressive or even a little rude to each other. GP meetings can be similar. However, when everybody is put into a room, the participants are much more polite and try to see things from the other person's point of view. It is a big deal to roll back specialism which is destroying medicine in the United States. I agree that geriatricians and GPs are of the pure specialist model. I am not a gastroenterologist; I am a general physician with a special interest in gastroenterology. I must engage in gastroenterology for outpatients, but the needs of my inpatients relate more to general medicine and it can be incredibly difficult.

Why would the old funding model change? The hospitals used to get X amount and X plus 5% the following year, regardless of change. I want to see activity-based funding, meaning that if there is change, there will be extra beds provided, if required. If there is no change, there will be no extra beds provided. To be fair to the HSE, it is introducing an activity-based funding model, although I would rather if it were an outcome-based funding moel. In any case, activity-based funding model is good. Chief executive officers are not interested unless we hit them in the pocket. If they realise that if they change the system and discharge diabetes patients to GPs, for example, they can shorten the time for new patients and be rewarded. This is related to a new-to-return ratio and if it is greater than two, the hospitals will be penalised. The Legislature could help as legislation would be needed at some stage to push people to change, which is very difficult.

Dr. Ronan Fawsitt:

On Deputy Billy Kelleher's point, there is institutional resistance; there is resistance to change everywhere and we have reached tipping point on the issue. There is a need to change what is broken. Deputy Michael Harty is absolutely correct. He has nailed it in that the health service is broken and in a perilous place. We need to provide for continuity of care, of which general practice is the only provider. There are enablers that will allow greater GP participation, particularly in urban areas. We have discussed them with the primary care directorate. It will require a small amount of funding, but there is a willingness to do it. Unless the State supports this, we will stay in the bubble for another ten years when we will be back before the committee.

It is absolutely vital that we get the GP contract right. It is the future for my kids and grandkids. We have not had a model for a new health system in 44 years. Legislators should remember the year 1948, after Britain had been destroyed in two world wars and when it was bankrupt, but it still had the vision and political determination to put money into the National Health Service which no Briton would give up today.

The question was asked whether the GP or the team had priority.

It is a team, a multidisciplinary team. The GP is not above that. It is a team and everybody is equal. That is the Carlow-Kilkenny model. We need a more team-based approach in the community, but led by the GP who will be ultimately accountable for that care.

As regards where the diagnostics should go and whether they should be physically independent, I believe they should be. Hospitals should be doing specialist, high-tech work. I do not believe that we should be sending them low acuity stuff in diagnostics. We should be doing this in primary care resource centres. The new 80 primary care centres that are to be built in Ireland in the next two years should become resource centres for investigations and service hubs for physiotherapists, OT, IT and so forth. Counselling, something so simple and vital in mental health, should be provided in a primary care resource centre. All GPs in County Clare or County Kilkenny should have one or two of those resource centres where that is recognised. It is not a parallel structure because, in a way, those patients never get to the hospital. They will be treated and cared for much more cheaply in a primary care resource centre than in a hospital.

There are 80 sites coming on stream and this is a wonderful opportunity to get this right, but we must consult with our local GPs. If a local GP has spent €250,000 on a new premises, without tax relief or the like, why would they move to a primary care centre? It might look wonderful, but it makes no sense. One must work with the GPs on the ground. If they are not willing to move into a centre, that is fine. Let us work with the centres in a different way. However, they must become service and resource centres. That is the value and that is what keeps people at home.

Professor Garry Courtney:

Deputy Collins asked about changing culture. When one says NIH to doctors, that means National Institutes of Health Bethesda in the United States, a wonderful research centre. However, in some parts of this country it means "not invented here", so if one has not invented it in that hospital, people are not interested. One must be very clever about it and make them think they thought of that idea in the first place, and they will do it. However, there is some resistance to change. Institutional rivalries come into this, as do professional rivalries. However, it is the patient who suffers at the end of the day.

Dr. Ronan Fawsitt:

Deputy Collins rightly referred to the 28% of older GPs who are due to retire. That is a worry and we must address it. The Irish College of General Practitioners is in a position where, with correct funding, it could take on more training to get us over this bump. We need our specialist generalist, who is the GP, in the community to mind patients. It is about care and continuous care. We must bite the bullet on that. We must keep our graduates here and if we do not have enough, we must train more for the time being. We must make Ireland attractive for our graduates. We must make it connected and join up the dots in health care. In our process we get 25 people to come into a room every month. It is no problem. They want to be there because they want to be involved in how we move forward.

Róisín Shortall (Dublin North West, Social Democrats)
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You referred earlier to the many perverse incentives within the funding model of the health service at present. How does one deal with an issue where it makes absolute sense from a patient's and a financial point of view to move a service out? A key decision must be taken by the hospital whereby it says it is prepared to give somebody X amount of money to do something in the community. Presumably, it is very hard to get hospitals to do that, because there are turf wars taking place. You are dealing with the community and St. Luke's. It is further complicated, obviously, in situations where there is the community, a HSE hospital and a voluntary hospital, which is another kettle of fish. At present, they appear to be getting the co-operation on a voluntary basis but with regard to rolling out this type of model nationally, presumably there would have to be clear decision making in terms of top slicing funding that currently goes to hospitals and switching that into the community. How is that addressed?

Professor Garry Courtney:

This is the real nub of the issue. At present, we have done it all for free. We met the GPs and said: "You are just admitting patients to hospital corridors. They are not really being well looked after. Will you give up that right and send them into an acute medical assessment unit?" They bought into that. It is more work for GPs and they did it for free. All of the diabetic patients are not seen in our hospital. The GPs see them for free. However, what did they get for that? One must give something and take something. They get a one week waiting list for a new diabetic. That is unheard of. As our diabetes doctors and nurses are not looking after all of those patients who are perfectly well managed in the community, totally stable and whom it is ridiculous to see in an acute hospital, we are able to see the acute ones. Why do we give them BNP, brain natriuretic peptide, tests? The hospital pays for the BNPs the GPs order, which is very expensive. Nobody else does that. However, if the BNP is high, we know that heart failure is developing. Dr. Fawsitt will write a letter saying he wants an echo. The echo is done and we do that for free. However, then he treats the patient. He does not admit the patient. Admitting the patients costs the earth.

Róisín Shortall (Dublin North West, Social Democrats)
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That is a lot of extra work for the GP.

Professor Garry Courtney:

Yes. I believe GPs are able for it and want to do it. Why should they not order tests and get tests for the patient? It gives them a greater esteem and respect. They are senior decision makers. When they say they want the patient seen in the emergency department, it happens immediately. We do that. It is the way hospitals work together. I run a liver unit. Not many hospitals outside of the massive Dublin hospitals run liver units, but because I do that and take a great deal of work away from Dublin, when I want Dublin to see a very sick liver patient, it sees them immediately. There is a respect.

It will not roll out unless there is funding behind it. That is why I believe legislation is incredibly important. Deputies are the representatives of the people. They absolutely should not abrogate health. I like the idea of not having a situation where health keeps changing when a new Minister takes office. I love the idea of having an all-party consensus. Ultimately, the people who stand for election are the Deputies and they must say that they agree on the direction of health and that they agree it is in GP-led primary care. What is in it for the hospitals? Hospitals will do acute care, which is highly complex work and gives us great satisfaction, and GPs will do the chronic care, which they should be paid for and from which they should get satisfaction. However, I do not believe it will happen very quickly - I wish it would - unless there is legislation behind it.

How I see it is that we would run a service level agreement, SLA, for the voluntary hospitals. The HSE will say that it must get the diabetic waiting list down to two weeks or whatever. That is how it does it at present. That is good. However, it should also say, "By the way, you must have a GP-hospital local integrated care committee functioning. We want to see the agenda, the minutes and the action points." The chair of that committee in our hospital is Dr. Fawsitt and if one asked him to see those, he can produce them all. There is a great deal of codology and pretend stuff, so one should write an SLA which states that there must be X number of scopes, Y number of gall bladder operations and whatever, and there must also be a local integrated committee. One can legislate for that.

Dr. Ronan Fawsitt:

I believe there must be ring-fenced funding which is legislated for and guaranteed to outlive the life of this Parliament and the next one. That is the way forward. There was a question about what is in it for the hospitals and for the GPs. We opened a new surgical assessment unit two years ago. I have a two week waiting list now in my public clinics for a lump or bump to be removed or to see a surgeon. We discussed this last night at our meeting. What did we do to achieve that? We said we would deal with the normal stuff in reports. If a surgeon removes a lump and it is benign, he will send me the report and I will tell the patient or the patient will ring me. They do not need to go back to the surgeon for a follow-up appointment, which is wasting the surgeon's and the patient's time. We take it on. Okay, it is pro bono. In a new contract that must be valued and costed, because it is the right thing to do. However, the value of such joined-up thinking, shared responsibility and shared care, where GPs are equal to the consultants, is that patients benefit. I have a two week waiting list now for a query melanoma or a query cancer on the face. The patient is seen by a surgeon within two weeks. That is what is in it for us.

Róisín Shortall (Dublin North West, Social Democrats)
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Sure, but there is a huge amount of additional work for the general practitioner, GP.

Dr. Ronan Fawsitt:

Yes, there is.

Róisín Shortall (Dublin North West, Social Democrats)
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There is a hugely increased workload and this must be recognised within the new contract.

Dr. Ronan Fawsitt:

Yes.

Róisín Shortall (Dublin North West, Social Democrats)
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The other aspect about which I am interested is the role of the Health Service Executive, HSE, in this regard. While it is fine to state activity will be switched to the community, unless the other allied health processionals - apart from GPs and practice nurses - are available and unless the primary care teams are adequately staffed, the care cannot happen in that setting. In working with the HSE, what scope exists to switch budgets like that or to provide additional funding?

Professor Garry Courtney:

That brings up the point made by Deputy O'Connell about divisions. When one thinks about it, we had five divisions in the HSE and even the word itself shows one there is not much cross-talk. Consequently, a cross-cutting concept is needed that makes the social division work with the primary care and acute hospital divisions. They are all separate at present. Coincidentally, a new structure has just been announced by the HSE that I do not fully understand. However, we think it is good where the royal colleges, the Irish College of General Practitioners and the HSE came together and developed the clinical care programmes. While the Chairman is aware of the diabetes programme, there are 33 of them and no other country in the world has that. That is the best care and is the plan of care for all patients. While that has been done here in Ireland and is all written down, I believe we have lost focus on the clinical care programmes. It is all written down for asthma, chronic obstructive pulmonary disease, COPD, heart failure, diabetes, liver disease or anything. There should be some cross-cutting ability stating that if the clinical care programme on obstructive lung disease indicates it should be managed in the community, it should be so managed. Moreover, if one finds out that a hospital never discharges such patients to GPs, who incidentally are well able to look after them, that hospital should then not be funded. I probably would pull back at the moment from penalising because if one penalises a hospital by withdrawing funding, it also hurts patients. However, it should not receive additional funding. The old model of having a problem in the winter, doing nothing about it and getting extra money must stop.

Róisín Shortall (Dublin North West, Social Democrats)
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At an early stage in our work, we were advised that we should recommend the establishment of a project management office to have in place a unit charged with responsibility for the implementation of whatever recommendations emerge from this committee. Such an overarching body with a focus on bringing about change is lacking at present.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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In response to Professor Courtney, I recall the meeting in Farmleigh well and have a somewhat different recollection of where the battle lines were drawn. My memory is of having a row with the Government representatives but that is neither here nor there. I have two brief questions, the first of which is on the unique patient identifier project which is under way. Will it help, hinder or make much difference? I hope it will help. Second, the witnesses who appeared before the committee earlier discussed differences in patient-to-GP ratios. Is the Carlow-Kilkenny region broadly representative of the country as a whole? Do the witnesses know whether the ratio in that region is higher, lower or average?

Professor Garry Courtney:

While Dr. Ronan Fawsitt can deal with the GP ratios, the implementation of the unique patient identifier would be wonderful. We could follow patients and could see trends. We have a different number for a patient who comes to us from Dublin for a holiday. The simple answer is it would save money and would reduce delay and duplication. It would be a brilliant idea and I hope it happens.

Dr. Ronan Fawsitt:

The work of Richard Corbet in this regard has been exemplary and must be supported. The electronic health record, EHR, is absolutely vital to an integrated, joined-up health system. We are doing it on a human level, which also is necessary, but an EHR would make everything seamless and accountable and is the way to proceed. While projects such as the national medical imaging system, NIMIS, Healthlink and so on are delivering, they must be extended. All I wish to say to the Deputy is this model works.

We are a microcosm of Ireland nationally in terms of population, the percentages and so on. As approximately 40% of our population - perhaps 50% now on foot of the introduction of the under-six scheme -have medical card entitlements, we are a highly representative group in respect of what can happen in the community.

Róisín Shortall (Dublin North West, Social Democrats)
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We seek the figures in respect of the ratios.

Professor Garry Courtney:

Interestingly and amazingly, counties Leitrim, Kilkenny and Meath have the lowest number of GPs per population in Ireland and yet our GPs are doing all this work.

Dr. Ronan Fawsitt:

That figure came out just two weeks ago and Deputy Harty may have seen it; I had forgotten it briefly. We actually are on the critical list regarding GP numbers in the future. While we get on with it, keep busy and are productive, this must be fixed. We must encourage GPs to stay and perhaps we can get greater training and can encourage them to stay. I attended an awards ceremony last week at which some junior trainees were being awarded a trainee prize and of those GP trainees at the table, half were planning to emigrate. Consequently, this is a real issue.

Róisín Shortall (Dublin North West, Social Democrats)
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Yes, that issue is coming up repeatedly.

Billy Kelleher (Cork North Central, Fianna Fail)
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I apologise to Dr. Fawsitt but may I ask a short question?

Róisín Shortall (Dublin North West, Social Democrats)
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Yes.

Billy Kelleher (Cork North Central, Fianna Fail)
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We are talking about primary care being the main driver of health care delivery in the years ahead and that probably is a goal with which everyone present can concur. It will be part of the primary care strategy, as outlined previously, and all the rest of it. In that context, the GP contract will be of critical importance.

Dr. Ronan Fawsitt:

Yes.

Billy Kelleher (Cork North Central, Fianna Fail)
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Obviously, the organisations that will be negotiating will be the Irish Medical Organisation, IMO, and the National Association of General Practitioners, NAGP. There is a different perspective when they are negotiating from the point of view of the remunerative aspect of the contract. As for the contract, what input exists regarding clinical outcomes? How will that be assessed?

Dr. Ronan Fawsitt:

The Deputy has asked a really good question and my belief is the college must be brought into that negotiation policy process, perhaps not necessarily to negotiate but to advise and inform as to what is a doable process or care programme that can be funded by the State and as to what is of value. Professor Garry Courtney spoke of value-based funding as opposed to activity-based funding. We could perform many procedures in general practice but it might be a waste. My personal view, which is shared by many GPs to whom I have spoken, is a role should be created for the Irish College of General Practitioners in these new contract discussions or negotiations in an advisory, if not an informative way. While it may be limited by statute to negotiating, I suspect there would be a huge willingness for the college to engage in that process. Were the invitation to come, I believe it would be warmly received. Moreover, it would inform both sides. The college has been around for a long time and it really is about care of patients and about standards and quality. I believe that would be a game-changer.

Róisín Shortall (Dublin North West, Social Democrats)
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That is a strong point we all will take on board. I also note the college is appearing before the committee shortly. On that point, I will bring this highly successful session, in which members learned a great deal, to a conclusion. The witnesses invited the committee down to visit to see at first hand and we might consider so doing. It certainly is highly impressive and members would love to see it rolled out nationwide. It is marvellous and I thank the witnesses for their work and their presentation today.

Is it agreed to go into private session briefly? Agreed.