Dr. Laura Noonan:

I will look at a few of the areas Dr. Murphy has spoken about briefly. Deputy Collins mentioned the idea of fragmented care and integration between primary and secondary care. I will not speak about the Carlow-Kilkenny model again, but we need to think about this issue. If we are reducing attendance and demand on secondary care it must be accompanied by a transfer of these resources into primary care, and this type of dynamic decision on the relocation of resources needs to be made. If GPs are to conduct the care previously provided by hospital consultants and hospital-led clinics, they need to be resourced to do so. They can do it once they are resourced.

On Deputy O'Connell's point on multi-morbidity capitation and remuneration, I am very concerned that anybody would think that GPs would target and hone in on patients with multi-morbidity issues or who live in areas of deprivation because they can make a quick buck on them. This is not possible. In most general practices, we see a wide range and diverse types of patients. Certainly, most people walking into my waiting room will not know whether a patient is on the GMS and has a medical card or is private, or whether a child has an under six card or is seven years of age. All patients sit in the same waiting room, are seen by the same doctor and nurse and are provided with the same care. Issues arise when it comes to referring onwards. Somebody with a medical card can access a service such as counselling in primary care. Somebody with no medical card and no private insurance finds it very hard to access counselling. There is no onward referral pathway for them to counselling in primary care because it requires a medical card. This is when health inequalities exist.

I am also concerned by the fact that we speak about patients who are more difficult and for whom we deserve more money. Every patient becomes a different patient on a different today. The patients who might take me three minutes this week could take me half an hour next week because something complex has happened in their lives. As GPs, we know patients in the context of their physical, psychological and social backgrounds and these items cannot be disregarded. They are so complex and so important. Starting off in a new practice I do not know my families and patients very well yet, but I know that over the years I will develop this relationship and I will understand the patients better. We cannot reduce patients to being either a complex or simple patient. While there are indicators that people have complex comorbidities and may be more difficulty, a mental health issue may arise in a patient the GP has not predicted may become a complex patient.

Access to mental health is inequitable. As I mentioned, patients who do not have a medical card cannot even be referred on to counselling in primary care. This is quite a difficult situation. Patients pay a lot of money to private counsellors.