Mr. Pat O'Dowd:

On the rural practice support framework, the pre-existing scheme involved the rural practice allowance, which was replaced by the rural practice support framework in May. The allowance was based on a circular issued in 1972. The eligibility criteria were such that the population had to be less than 500 in the centre. The difficulty we had when we started examining this in 2013, in terms of preparing for contract negotiations, was that there was a lack of specificity and no definition as to what exactly the centre was. Is the centre the dot on the map or a catchment area to be serviced by the practice? It proved difficult and it was clear to us that the manner in which times had changed was such that the circular was something of an anachronism and needed to be upgraded and based on more objective and easier-to-define criteria.

There was also a restriction on the general practitioner. In order to qualify for the allowance, he or she had to be residing in the immediate area, which was probably reasonable and understandable at that point in time. With the emergence of better road transport, telecommunications services and the provision of enhanced GP out-of-hours services, we believed the restriction was actually serving as a further disincentive to attracting general practitioners to apply to be on a vacant GMS panel. We examined what we considered to be a more objective model, based on a defined geographical area. We geomapped all the practices in the country using our health intelligence capacity within the HSE and we were able to identify the populations served by each practice within a 4.8 km radius and an 11.7 km radius. We then settled on a rule set stating that if the population within a 4.8 km radius was 2,000 or less, it meant the practice would be ordinarily eligible. We also relaxed the rules around the obligation on the general practitioner to reside in the immediate area. We allowed some flexibility in that regard to make it more attractive for general practitioners to apply for positions.

The net effect was that we entered negotiations with the Irish Medical Organisation under a framework agreement, and we settled and agreed on a new rural practice support framework. As a result of that, the number of practices that are eligible and receiving rural practice support has increased. We now have 253 practice units receiving the support. Prior to the introduction of the scheme, there were 167 recipients.

In addition, the allowance element has increased from €16,000 to €20,000 per practice unit. The rural practice allowance is more than just the allowance; it brings with it other enhanced incentives. For example, a general practitioner receives subsidy support for employing nurses and secretaries. It is based on panel size. If in a non-rural practice there is a panel of 400, one gets four twelfths of the applicable subsidy. By being designated a rural practice benefiting from the rural practice support framework, one actually gets the full subsidy applicable for employing a nurse or secretary. One is also entitled to the full locum contribution allowance for annual, maternity and sick leave, etc. When these are all added together, they amount to a quite significant benefit for designated general practitioners. We estimate the value, on average, is in the order of €40,000 to €45,000 per practice. The cost of implementing the new rural practice support framework is between €5 million and €6 million approximately .

I shall now talk about the distance code, as alluded to by Mr. Hennessy. This feature was an integral feature of the GMS fee structure until 2010, and it was then removed under the FEMPI regulations, by statutory instrument. It is estimated that the full-year impact value of the removal of the distance codes is between €5 million and €6 million. I accept, however, that it would have had an increased impact on rural practices, by definition. That is almost self-evident. We have to concede that it did have an impact on rural practice, by definition, although not exclusively. By the same token, the rural practice support framework has introduced some additional funding into rural general practice. Since it was part of the fee structure and because it was amended or revoked under FEMPI, it is not within the HSE's gift to replace or introduce it. The fee structure is ultimately not a function of the HSE. We do not have any direct power or authority to alter the fee structure. It is set centrally and requires ministerial approval. It is not open to the HSE to alter it.