Oireachtas Joint and Select Committees
Thursday, 2 February 2017
Joint Oireachtas Committee on Health
Primary Care Services: Discussion
9:00 am
Michael Harty (Clare, Independent)
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The purpose of the meeting is to discuss primary care services, with particular reference to GP manpower and capacity issues in a properly functioning primary care service. On behalf of the joint committee, I welcome Dr. Pádraig McGarry and Dr. Austin Byrne from the Irish Medical Organisation; Dr. Karena Hanley and Dr. Brendan O'Shea from the Irish College of General Practitioners, and Dr. Emmet Kerin and Dr. Liam Glynn from the National Association of General Practitioners who will provide us with their perspectives on key elements of general practice.
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. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Any submission or opening statement submitted to the committee may be published on its website after the meeting.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
Before we engage with the witnesses I wish to declare the following interests for the public record. I am a contract holder with the Health Service Executive, HSE, to deliver general medical services to medical card patients. I am a registered general practitioner with the Medical Council of Ireland and I am an ordinary member of my representative organisations, the Irish College of General Practitioners, the Irish Medical Organisation and the National Association of General Practitioners.
I now invite the witnesses to make their statements, beginning with the National Association of General Practitioners, NAGP.
Dr. Emmet Kerin:
Chairperson, Deputies, Senators and colleagues in health care, we wish to thank the committee for inviting us here this morning to discuss general practice and its role in fixing our broken health system and the manpower crisis it now faces.
My name is Dr. Emmet Kerin and I am the President of the NAGP, which represents 1,920 of Ireland's 3,000 general practitioners, GPs. I am here with my colleague, Dr. Liam Glynn, who is the NAGP chair of communications. We are both full-time practising GPs in urban and rural practices, respectively. Our patients are directly affected on a daily basis by the issues we will discuss today. We strongly support the work of this committee and the Oireachtas Joint Committee on the Future of Healthcare committee in the development of a ten year plan for healthcare. The NAGP has also advocated for such a ten year plan.
We have an upside down health care system which is hospital-centric. Our hospitals are overwhelmed. To address this, we need a paradigm shift in health care, away from hospitals and towards GP-led primary care. GPs know their patients. They are the senior decision makers in the community and can lead team based health care which is person centred and population focused. GP-led teams are ideally placed to keep more patients well, cared for close to home and out of costly hospital care.
To achieve this, we need to support general practice. This means two things: First, we must provide proper funding for general practice similar to other OECD countries; and, second, we must provide enough GPs to lead and deliver the required primary care service for the population. Unfortunately, we have a manpower crisis of monumental proportions in general practice. Every year some 50% of our newly trained GPs emigrate. That figure is growing. We need 4,500 GPs by 2025 in order to provide safe, effective and efficient general practice. The challenge is stark.
Recruitment of GPs is a global issue but we are exporting our GPs. We are competing also with Canada and Australia where general practice is supported by adequate resources, access to diagnostics, with a better work life balance and career structure. We need a new GP contract which is fit for purpose and which will attract our young, highly trained GPs back to Ireland. This is critical if we are to facilitate the shift to a GP-led primary care service that is central to the future of healthcare. I am glad to say that the NAGP is actively engaged in this process.
We need special supports to attract GPs to work in urban deprived and rural settings. Here, the use of technology with virtual clinics and the networking of singlehanded rural practices is especially important. We need to support the pivotal role that practice nurses can play in addressing this issue. We need increased numbers of practice nurses with roles in chronic disease management. We would also welcome the addition of health care assistants, physician assistants and clinical pharmacists to work in general practice as part of the new clinical team. This team can provide services such as chronic disease management, residential care, minor surgery, end-of-life care and enhanced acute care in the community, especially for the frail and elderly. To build primary care we need to develop a new business relationship between primary and secondary care, the hospitals, as equal partners in a health care system based on shared and integrated care. Direct GP access to acute hospital services such as acute medical and surgical assessment units and pathways need to be developed. Over-reliance on the emergency department route needs to be fixed. Hospitals are there to support primary care, not the other way around. This culture change will take time but must happen through local discussion.
Such local engagement can be assisted through the Irish College of General Practitioners, ICGP, supported local integrated care committees, based on the Carlow-Kilkenny model where GPs, consultants and management work together locally to improve patient care. This should be funded and developed nationally. We need a formal agreed transfer of chronic disease management into the community. We also need to align information and communications technology between GPs and hospitals, a shared electronic health care record is vital for proper flow of patient data between community and hospitals. We need to ensure that primary care resource centres are developed to act as service and diagnostic hubs and that these are accessible to all patients and GPs in each catchment area. That is not the case for the primary care centres at the moment.
The Deloitte report to the Royal College of General Practitioners, RCGP, in 2014 showed that every €1 spent by GPs in primary care on people aged more than 65 saved €5 in the hospitals. This also gave better patient satisfaction and health outcomes. It is now recognised that we must make a decisive shift to GP-led primary care. All GP colleagues in the room today agree; and, the HSE, the Minister for Health and our health and social care colleagues agree.
This journey needs a ten year time frame and a new GP contract that supports this plan. It needs ring-fenced funding to make the transition. It needs political certainty to succeed. GPs are ready and willing for the challenge. That is why we are here today. We hope we have provided some clarity on the challenges but, more important, on many of the solutions to achieving a health care system we can all be proud of. We look forward to your questions on any of these matters.
Michael Harty (Clare, Independent)
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I thank Dr. Kerin. I call on the Irish Medical Organisation, IMO, to make its opening submission.
Dr. Pádraig McGarry:
The IMO thanks the Chairman and the members of the Oireachtas Joint Committee on Health for the invitation to discuss GP manpower and capacity issues in a properly functioning primary health care service. I am a GP in Longford and am also chairman of the IMO GP committee. My colleague, Austin Byrne is on the GP committee and is a GP in Tramore, County Waterford.
The argument that general practice is the optimum vehicle to deliver health care in the community setting has been made and proved without doubt and has been cited in a multiplicity of documents and research reports. That there is a capacity crisis in general practice in Ireland is therefore without doubt and this is manifest in the reality that practices and general medical service, GMS, lists, which heretofore would have attracted multiple applicants, can no longer attract a single applicant. In Thurles recently a practice of 1,200 patients which would have attracted a line of people a few years ago, cannot get a single applicant. That highlights the real problem.
The age profile of current GPs point to over 17% of current stock ready to retire in the next few years with little chance of replacement by newly trained GPs; 24% of GPs are over 60 years of age. Newly trained GPs indicate that they intend to emigrate to other jurisdictions where they feel their talents are better appreciated and their aspirations from a professional and financial perspective are more achievable. Newly trained GPs are also reluctant to commit to a health system which is failing as a result of the draconian reduction in funding foisted on general practice in the past few years. They would like to stay but circumstances are driving them out.
The resource cuts of 38% foisted on general practice have resulted in an inability to employ the staff required to deliver service to patients in a safe manner. GPs are being stretched beyond breaking point with workload and general practice is being shunned as a career by those coming out of college. They see what has happened. With an aging population, an additional 20,000 patients aged 65 years annually coming on stream, a cohort which brings with it additional workload, this situation can only deteriorate unless very clear decisions are made and implemented. The IMO has submitted a document which outlines the causes and offers solutions as follows.
The IMO calls on the Department of Health and the HSE to agree a strategy with the IMO for the development of general practice in Ireland in future decades. To ensure the maximum benefit for both patients and the health system the strategy must include a manpower action plan to address the growing shortage of GPs and to include an increase in the number of GP training places and an assessment of practice staff needs including assistant GPs, practice nurses, managers and other support staff. In order to halt the exodus of newly qualified GPs, priority must be given to negotiating a new GP contract with the IMO that is properly resourced and fit for purpose for a 21st century health service. Incentives must be provided for the development of infrastructure including premises, medical equipment, diagnostic equipment and IT, as per the recommendations of the Indecon report which was submitted last year. Access to diagnostics and allied health and social care professionals in the community are a necessity. There must be a commitment to preserving the positive traits of general practice, including the community-based same-day appointment service where possible, the GP independent contractor model and, the role of the GP as gatekeeper to the health system. Access to GP care should be expanded on a phased basis taking into account income and medical need rather than being based on age cohorts. All of the above must be resourced properly. That is the nub of the issue. I hope we can provide additional insight to the health committee and enable it to provide support for the suggested measures. We are happy to address the questions of members.
Michael Harty (Clare, Independent)
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I thank Dr. McGarry and call on the speaker for the Irish College of General Practitioners to make the opening statement.
Dr. Brendan O'Shea:
On behalf of the Irish College of General Practitioners, ICGP, I thank the committee for asking us to come and reflect with its members on manpower in general practice in particular. I am Dr. Brendan O'Shea, a general practitioner in Newbridge. I am medical director of a co-operative and I am the director of the postgraduate resource centre, PRC, in the Irish College of General Practitioners. I will invite my colleague to introduce herself.
Dr. Brendan O'Shea:
It is the consensus within the ICGP that general practice reached a tipping point during 2015, due to the onset of the under-sixes contract, influenzal activity, advice from hospitals for patients to attend general practice and increasing volumes. We have a more detailed submission which we hope is mercifully short. It includes an analysis of the situation, but we are interested in solutions this morning.
We know the problems facing the health care service and we refer members to the briefing document. We also believe we know the solutions. In the accompanying briefing document we have outlined solutions for primary care based on the following headings. The first is the cost efficacy of general practice. A well developed general practice is a key feature of higher performing health systems than our own. Another part of the solution, as my colleagues have outlined, includes building capacity in general practice. We have 3,900 general practitioners and approximately 1,700 practice nurses who work largely on a part-time basis. We believe that if want to deliver chronic disease management in this country and if we want to unburden the hospitals of primary care work and bring it into the communities we probably need closer to 5,000 general practitioners and, arguably, 5,000 full-time practice nurse equivalents. The ratio between general practitioners and nurses in general practice in the United Kingdom is closer to 0.8 while in Ireland it is closer to 0.2 or 0.3. We are seriously understaffed in both grades, in particular practice nurses.
Another part of the solution is to extend the use of information technology out of general practice where it is well established and into all other parts of the health system. A further part of the solution to the problems that are being faced by the health system is delivering care where people want it. People want their care to be delivered in communities and closer to home not in hospitals. We believe building on current experience and expertise is part of the solution. We need to move on. The key issues facing general practice and primary care are recruitment and retention.
Dr. Karena Hanley:
We know there will be a shortage of approximately 1,000 GPs in the next ten years. That figure comes from a national manpower planning study. Dr. Kerin spoke about the loss of trained doctors as soon as they finish GP training. It is most important that we look at ways of retaining them as well as producing more doctors. Let us look at solutions for retention. General practice is an attractive career. Drop-out rates during GP training are low but GP trainees fear that Irish general practice is not a viable career choice. General practice in Canada, Australia and New Zealand is better resourced and those countries actively recruit here. Their agencies are making it easier for our trainees to go. As well as the economic loss it is a cause of sadness and ill feeling. Emerging GPs want to do good chronic disease care for their patients in the community if appropriately resourced.
In terms of gender, under half of the general practice workforce is female. Two thirds of women doctors work full time but they tend to work part time in their 30s, which is a time of intense child rearing. A proportion of male doctors also work part time but there is a lack of flexible working options in the current GMS contract. Some doctors who are employed by a practice do not hold a contract with the State. Those doctors often do not receive any maternity pay or sick pay, as struggling practices now cannot afford to pay them. Much better terms of employment are available to young doctors in neighbouring health systems in the UK, Canada and Australia. As we have heard, access to diagnostics will help. Some improvement in access to ultrasound was achieved in some areas of the country in 2016. That is good but we need to build on it. Some older GPs intend to continue to practise beyond their contracted retirement age. That needs to be welcomed, planned and supported, with flexibility in the contract.
I will now turn to recruitment. The national doctors training and planning, NDTP, unit tells us we need 100 more GPs to be trained every year. The programme for Government agrees with that. The ICGP supports that goal, and can deliver it, if resourced. The ICGP will continue to work with the NDTP and primary care to increase GP training places. We are currently training 172 GPs per year. In the past six austere years, the ICGP delivered a 43% increase in training places with barely any increase in resources. The dilution of GP training must be avoided as dilution will result in less resilient GPs with fewer skill sets, and will not help retention.
Dr. Brendan O'Shea:
If the committee assists in building capacity in general practice in the years ahead it will have done great work. We wish to reflect on building capacity in the general practice team. The primary care team was referred to from 2001. A lot of time and effort has gone into it. Arguably, the outcome from that has been somewhat disappointing. Our interest is in building capacity in general practice teams. Capacity in general practice is not just about GPs. We want to build capacity so that we have GP-led primary care management of chronic disease in the community. That will require an increase in all general practice staff. GPs have the capacity to delegate work within their practices but the people to whom they delegate their work must also be appropriately trained and funded. The concept is in keeping with the principle of enabling GPs to work to the higher end of their skill sets and contracts, leading to even more productive teams under the independent contractor model.
In the briefing document, we elaborate more on the following topics, including how to recruit and train more practice nurses. In the ICGP we collaborate with our practice nurse colleagues in that regard. We are also examining how to increase the number and capacity of practice managers and administrative staff, how we can interact and how the primary care team can be more effective as well as the extension of information technology, which in the Irish health system is really only located in general practice and must be disseminated into all other parts of the health system. In colleges and university departments of general practice we can deliver ongoing research and educational support to effect those changes. We are coming to the committee this morning with solutions and the members must put energy into those solutions, if they can do that.
Dr. Karena Hanley:
Ireland will continue to see an exodus of GPs unless clear actions are taken now to attract them to stay. We must examine how that will affect communities, the elderly and patients in general. We recommend the delivery of a GP contract in 2017. We also seek supports for emerging graduates from GP training and flexible working options in general practice. General practice is successful. In terms of value for money, general practice has been one of the most successful public private partnerships in the health system but actions must be taken to address the infrastructure of general practice.
These actions must recognise that GPs carry all the obligations and liabilities of providing the complete service. We are giving away our GPs. They are not returning in any significant numbers. In the words of one recent graduate, now in Canada: "It would have taken so little to help me stay, it will take so much more for life to bring me back."
Michael Harty (Clare, Independent)
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I thank all of the witnesses for their opening statements. Before I open up the discussion, many of the members here today are also members of the Committee on the Future of Healthcare. There is an understanding among all of the experts who have appeared before us that general practice is the core of how we build our future health service. In that regard, we would like to direct our questions to how general practice can support this new health service. I will take questions in groups of three as follows, Senator Burke, Deputy Murphy O'Mahony and Deputy Kelleher.
Colm Burke (Fine Gael)
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I thank the witnesses for their comprehensive presentations. I agree with what was said in regard to support for GPs. It is fundamental that we develop this area in respect of which the cutback in funding has been substantial over the last few years.
One of the concerns for me in regard to health care is the many different groups in the area in need of funding. The Irish Nurses and Midwives Organisation, INMO, is seeking the recruitment of more hospital staff. Everyone is looking for more funding. As a country, we are the second highest in the OECD in terms of the level of spend in this area per head of population. The question that arises then is where we are going wrong in terms of funding. I agree we need to resource GPs but I am concerned about how we are going to address issues such as the fact that we have only 2.8 hospital beds per 1,000 of population while the average across the OECD is 4.3; and the huge demographic change that is approaching at a very fast rate in terms of the number of people aged over 65 years expected to increase from 600,000 to over 1 million by 2030. Approximately 51% of our hospital beds are occupied by people aged over 65 years. How can we cater for this and at the same time improve the support for GPs so that more people can be kept out of the hospital system?
In my own area in Cork the population has increased from 410,000 in 1986 to 542,000 in 2016, which is an increase of 130,000, yet not one additional hospital bed has been opened. We are asking GPs to do all of the work they are required to do at local level but to do so they need the backup of hospital services. Where are we getting it wrong in relation to funding and where can we make the savings while at the same time put additional funding into the development of GP practices and supports for such practices?
Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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I thank all of the delegates for being here. Some of the information they provided is very worrying, particularly the high percentage of trained GPs that are emigrating and the age profile of those remaining. I presume if this continues we will reach a crisis point. Now is the time to ensure that does not happen.
How many practices currently have vacancies that cannot be filled? What percentage of graduates from the GP training schemes end up practising? In terms of solutions, would the reintroduction of the distance codes enhance newly-trained young doctors opting for rural GP practices? The co-operative system is a huge success in west Cork. Are there plans to expand that system? Similar to the subvention for practice nurses, would it be helpful if a retiring doctor could access a subvention to enable him or her to hire an assistant young doctor? In regard to the perceived shortcomings in the hospital system with regard to early discharges and so on, how does that impact on a GPs every day practice?
Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the witnesses and thank them for their presentations. I have the privilege and honour of also being a member of the Committee on the Future of Healthcare. It is an exciting time in terms of the discussions that are taking place. Everybody around the table will, I am sure, have a similar view in regard to how we deal with the changing demographics, the increase in population and transferring chronic disease and chronic illness from the acute system into the community and primary care system. We are all agreed, and all of the reports and evidence would suggest, that this is the right thing to do. How we implement that plan and the transitional phase will require an awful lot of front-loaded funding in terms of enhancing primary care. There is not much point enhancing primary care if all of our GPs are in Canada or Australia and so we are faced with a huge challenge.
Along with that, we are not training enough GPs. This is not about retaining what we have, we need to expand capacity substantially. Reference was made earlier to the need for an additional 1,000 GPs. If we are to be honest with ourselves, there will be challenges in terms of ensuring that every practice is viable. That is always going to be a challenge. In that context, perhaps the witnesses would elaborate on their views on the difficulties being experienced in terms of recruiting GPs in certain areas and on GP salaries.
The bulwark of primary care is delivered by GPs in their surgeries. This is based on a 44 year old contract. I am aware of the ongoing discussions and negotiations on a new GP contract. Let us be under no illusions, that is the critically important component in the delivery of primary care. If that contract is not remuneratively advantageous or at least attractive, GPs will continue to flow outwards. In that context, who in the negotiations is examining this issue purely from the clinical aspect? In other words, who is advocating for the policies? With the best will in the world unions are unions and they will advocate for their membership first. In terms of our attempts to ensure there is enhanced capacity and so on in primary care, who is the voice of reason in the context of the negotiations in terms of what will and will not work? Does the Irish College of General Practitioners have a role in that regard? I previously raised that question with the Minister and he said he would consider it? Whether that is happening or not, I do not know.
The National Association of General Practitioners has 1,900 members. The IMO has 1,600 members. Leaving aside all of the bartering and toing and froing in advance of the negotiations about representation and so on, are both parties equally represented at the negotiations? Is there a lead negotiator or is there parity of esteem? The witnesses might elaborate on that point.
If would be extraordinary if after all of this, half our GPs are outside the door and looking in the window. If we are to get this right, the negotiations will have to be as representative as possible. If one organisation is involved and the other is not, the committee will have to raise the matter. It would be wholly inappropriate for us to be discussing the most important issue facing the delivery of our vision for health care if all GPs are not represented in the negotiations on the new contract to ensure it is teased out to the point where everybody gains. I include in this regard the Committee on the Future of Healthcare and the plenary debate of its report in Parliament following publication. This means the negotiations need to be as broadly representative as possible. If it is not the case that all GPs are represented, the committee will have to have a discussion on it with a view to raising it with the Minister.
Reference was made to the Kilkenny model.
Recently, we discussed with consultants appearing before the committee the issue of GPs coming to the hospital, working with the hospital and greater links between consultants in the acute system and GPs in the primary care system. There is also the matter of access to diagnostics. We have heard varying views on access to diagnostics for GPs. Some people say it is critically important while other clinicians of equal eminence say it is not necessarily the best way to go. When the witness speaks about access to diagnostics, what type of diagnostics is meant?
There is planned elective surgery, elective appointments and elective diagnostics. Whether that moves smoothly depends on the flow through the emergency department. If there is not a great flow through the emergency department the elective surgeries and diagnostics take place on time, but if there is a build up in the hospital they all fall behind. There were cases as recently as this week where breast surgery was cancelled just before it was due to take place. That is really traumatic for people. Should diagnostics in certain areas be separate from hospitals? In other words, there would be regional diagnostic units that would function away from the hospital setting and not be dependent on what happens in the acute system. Otherwise, they would be swallowed up again by the acute hospital system.
In addition to the role of the nurse specialist, is there a role for GPs specialising in certain areas as well, if we are to expand the GP service and the number of GPs? I realise that general practice is a speciality, but within that context there might be GPs who work in the respiratory area, for example. Is there a possibility that one could build expertise in hub areas within primary care as well? Perhaps the witnesses would elaborate on that point.
Finally, what is the view of the representative bodies on the role of community pharmacists? I accept there is a substantial difference between diagnosing and dispensing, but they spend a great deal of time in college too and most of them are quite bright people. In view of the fact that they have premises in almost every village and town in the country, could they play a greater role in the delivery of primary and community care, obviously under the guidance and lead of the GPs?
Michael Harty (Clare, Independent)
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We have heard a huge array of questions. To keep the flow of the meeting going perhaps one representative from each organisation would respond, although I am not trying to stifle discussion, and keep their answers as focused as possible.
Dr. Liam Glynn:
I will respond to Senator Colm Burke, whose question was very pertinent. He has identified the two key issues we have a problem with in the Irish health care system. One is in the hospital system, where there is undoubtedly a bed capacity problem, and the other is in the primary care system, where there has been huge under-investment for many years. The answer to the Senator's question is twofold. We must deal with bed capacity. However, if we invest in primary care, the pressure will come off the hospital system. The issue we must get real with is that we will have to front-load the funding for primary care.
One of my roles as an academic is to look at this in detail and the data and a huge amount of international evidence show that we will get a bang for our buck if we put the money into our primary care system. We know that one extra GP per 10,000 patients has an effect in reducing emergency department attendances and outpatient visits. If we reorientate in that direction we will get a return on the investment very quickly. The famous Rhode Island experiment is often quoted. The state of Rhode Island in the US reorientated its health care system towards primary care and it got a fifteenfold return on its investment, even greater than the €1 for €5 that was already mentioned. That was achieved within a 12 month period. The crucial issue is that we must believe that we will get a return on investment if we resource primary care.
Dr. Austin Byrne:
I will respond to Senator Burke. It is refreshing to hear insight in terms of sound economic assessment and evaluation of capacity issues, bed numbers and GP numbers. The committee, thankfully, appears to have a very good grasp of that. The Senator mentioned that we are the second highest in the OECD in spending and asked why we have such a problem. The key issue is that over the past eight or nine years we have built up a huge deficit in capacity at both hospital and general practice levels. We have also built up a deficit in funding. Capital infrastructure spending has been almost non-existent. Our bed ratio is 2.8 beds per 1,000 in population, which is really low. The committee is not seeking to discuss accident and emergency departments but it is worthy of mention.
On addressing the immediate issue of bed capacity, and Deputy Kelleher mentioned beds being blocked through accident and emergency attendances in terms of elective surgery planning, unless we get down to an 85% bed capacity the hospital system simply cannot function efficiently. There is a view that it costs €1 million to open a bed, but it does not. Certain types of bed cost a great deal and certain types do not cost quite as much. That is the first matter. We must add bed capacity and it need not all be high dependency bed capacity. If we offer extra capacity to our hospitals, we will free up beds for movement of patients and patient flow. As we add beds, the cost per bed will drop off. The other key issue is that our bed structure is highly fragmented and our cost per bed is highly variable throughout the system. That requires careful examination, and it is not a job for today.
With regard to the separate groups, the Irish Medical Organisation, NAGP and ICGP are here today and there is the Irish Nursing and Midwives Organisation. Everyone is looking for funding. Looking at the fundamentals, we can say categorically that we have the lowest number of general practitioners per head of population in the western world. That is a fact. We have the highest number of nurses per head of population in the OECD. That is also a fact. Rather than looking at absolute numbers, we must look at the structures and patterns of work flow. It is fair to say that many of our nursing colleagues would prefer to be working differently and smarter and, to use Dr. O'Shea's phrase, to be working to the upper end of their contracts or their skills sets. We must develop the mindset of passing units of activity down to the lowest level of skills sets. We need to farm certain activities down through the chain of activity - work our nurses and our GPs up to their game.
There must be serious amounts of front-loaded investment. Our CEO announced in the past two weeks that he estimates €9 billion is required. That is quite a conservative estimate, and it is difficult to state a number such as €9 billion without swallowing hard and taking a breath. However, €9 billion in the broader scheme of things, in terms of investment and the accumulated deficit over the last eight to ten years, is not an awful lot of money. Bear in mind that if we do not make that front-loaded investment, and the Department of Public Expenditure and Reform finds it very difficult to sign off on the like of that, the cumulative deficit will continue to roll over and expand and the cost of providing care into the future will enlarge.
We then look to general practice as a solution. I do not like the term "primary care". Primary care is not general practice. There has been much investment in primary care over the past number of years. Centres have been developed. They cost quite an amount of money to put in place. The general experience among general practitioners, myself included, is that they are good buildings in good locations and easy for patients to reach, but they are largely unstaffed. Where they are staffed it is by staff who have been relocated from hospital sector locations into the community on a part-time basis. There are no additional units of activity or workload carried out by the staff who are relocated and who are working at capacity.
The further issue for the GP next door is trying to access a physiotherapist, for example. A GP referral will receive a low priority triage, priority four, unless it is an acute injury. A hospital discharge will be priority one because it comes from the hospital silo. The physiotherapist who is now relocated to the primary care unit, therefore, at additional cost of room occupancy and the additional cost of mileage allowances to and from the primary centre of work, is largely performing the same activity they always performed. They are working at capacity but we have brought another layer of inefficiency and another layer of cost into the system.
This brings us back to the initial question: Why are we spending so much? We are spending so much because we are carrying out the wrong activities in the wrong centres and we are carrying out activities at higher levels of cost than is necessary. We are carrying out routine disease reviews and medication reviews in costly outpatient settings because we do not have the capacity, the funding or the ability. We are simply not allowed to perform it under contract in the community. If we do perform it, we are straying out of contract and incurring a cost to the practice which is currently on the edge of viability in enough cases.
Dr. Brendan O'Shea:
The questions are really interesting and important ones and we would like to stay here all week to discuss them in detail. Senator Burke's question on where the funding should go is particularly important and we would concur fully with the observations of our colleagues. The big picture thinking is that, in this country, we spend approximately 2.5% of our budget in general practice in the primary care part of the system, while the NHS currently spends 8% and it is moving towards 11%. If the committee can advise the Oireachtas so that the Oireachtas makes correct decisions to effect that type of distribution, then we have the solutions.
The most important, effective and efficient part of the health system is arguably general practice. We are pleased and delighted that Deputy Murphy O'Mahony perceives the co-operatives as being highly efficient. They are efficient because they are run by general practitioners and are under the business umbrella, if one likes, of the independent contractor model.
Where should the money be spent? More of it should be spent in primary care, particularly in the general practice part of it. Another important question relates to where the diagnostics should be located. It takes six to nine months to get an MRI or an ultrasound. If we have standalones in primary care centres or hospitals delivering these services, as long as the access is equal to all citizens and efficient the Irish College of General Practitioners does not have a strong position on where the diagnostics should be located. How efficient should it be? Several years ago our colleagues in the Royal College of General Practitioners were appalled that it was taking more than six weeks to get a routine ultrasound so they decided that general practitioners should deliver ultrasound themselves. They engaged in training and now have a training programme and provide GP ultrasonography. This is part of what they are doing with their money and how they are using some of their 8%, as opposed to our struggling on the 2.5%. There are various solutions.
Dr. Hanley will take over now, but I wish to make one last observation. We all, including our colleagues in the HSE, have failed particularly the public patient in our industrial relations, IR, process over the past years. We sincerely hope that we are moving towards an ongoing consultative and evolving contract that is examined every 18 months and that never again will it it take 38 years to do it.
Dr. Karena Hanley:
Deputy Murphy O'Mahony asked how many of our graduates continue to practise in general practice. We have really good news for the Deputy. General practice training works. It has a very low dropout rate and very good retention. Some 92% of graduates from GP training remain practising as GPs, although, alas, at the moment not all of them in Ireland. The other important point is that retention of GPs trained in a rural area is very good. For example, in the past 30 years, of the 100 doctors trained in County Donegal, 50 have stayed practising as GPs in County Donegal. County Cork has an even higher retention figure. Train the GPs in rural areas and they will stay there.
Deputy Murphy O'Mahony asked about practice vacancies. The number of vacant lists have been accelerating. It was approximately 14 in 2014, 21 in 2015 and now is 24. The number is increasing. She also asked about subventions for young doctors such as having a subvention for an older GP to take on a younger partner. That is one of the suggestions in the ICGP vision for rural practice. Of the four recommendations for rural practice, which include education and training initiatives, financial incentives and locum supports, the other recommendation is to fund a rotating assistantship. This was successfully done in my practice when we had better funding, but we do not have the possibility of doing it at present because the level of funding is so badly reduced. I will pass onto my other colleagues to answer other questions.
Dr. Emmet Kerin:
I am not too sure of the order in which we are taking the questions. I will start with the issue raised by Deputy Kelleher on parity in the contract negotiations. I agree it is important to address the issue because it is very important that all voices are heard. As it stands, we have in excess of 1,900 members. We submitted audited numbers of 1,800 at the time. I understand that the IMO currently has 1,600 members. What is happening here today is historic. We have the three organisations here and we can see the commonality, the overlap and the same thinking and process. As stated by the Minister, the new GP contract which is to underpin this shift to GP-led primary care is core. I like the term primary care. It encompasses all our allied partners, from dieticians to podiatrists and physiotherapists. We will have our second primary care partnership conference at the end of March this year with international experts informing us of what works. For any GP who was involved in the primary care partnership, there was an amazing synergy and energy last year when listening to our primary care colleagues on how we can best work together. We need to work on that further.
On the contract, we sought clarity on it because, as it stands at the moment, we are dealing with the semantics of negotiation and consultation. There has to be clarity, which we have sought, and we are waiting for the Department of Health to give it to us. We have parity on the input and the output. We all need to work together. If that is not the case, I cannot see how the process can work, but we are awaiting that clarification from the Department of Health.
Billy Kelleher (Cork North Central, Fianna Fail)
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In terms of the contract negotiations, who is examining it from the clinical aspect? Leaving aside that the organisations have to negotiate on behalf of their members, who is in the room to ensure that the policies are represented as well? The Department has a view too. It wants to keep costs down.
Dr. Austin Byrne:
On that very question, the IMO has a close working relationship with the ICGP on clinical issues. There would be commonalities as to what is needed. Patient care will be looked after in that respect. We all have an ethical duty to ensure that that takes place. I do not think we will be found wanting in that respect. It is something that is foremost in our mind.
Billy Kelleher (Cork North Central, Fianna Fail)
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I would not say that the Department of Public Expenditure and Reform might be acting ethically in terms of assessing from the medical point of view-----
Alan Kelly (Tipperary, Labour)
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It does not have one.
Alan Kelly (Tipperary, Labour)
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You could actually. We all have to deal with-----
Dr. Austin Byrne:
What the Department of Public Expenditure and Reform does in relation to funding is a core issue. The political body has to ask if it, the Oireachtas, is committed to providing an appropriate resource for a working health system. If not, the Members are letting down their constituents and the public. It is a huge issue that is broader than any of us. The members are the representatives and that is a question they have to ask the Department of Public Expenditure and Reform. They need to put the appropriate pressure where it is required. We will certainly work on the question of standards.
On contracts, although I thought we were here to discuss capacity today and how we might provide solutions-----
Billy Kelleher (Cork North Central, Fianna Fail)
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They are interlinked.
Dr. Austin Byrne:
In any event, on where we stand, the IMO received an invitation at the end of December to re-involve itself in the negotiating of the contract under the 2013 framework agreement between the Department of Health, the HSE and the IMO. That is a legal document naming three parties. We sought clarification on what would be the situation if the terms were changed. The clarification we received from the Department of Health was that the IMO, the Department and the HSE would be negotiating under the framework agreement and that a second consultation process would take place between the National Association of General Practitioners, the Department of Health and the HSE.
That is the clarification we got.
Michael Harty (Clare, Independent)
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Will the negotiations for a new contract to underpin the health care system in the next ten years exclusively involve the IMO, with the NAGP being involved on a purely consultative basis?
Dr. Pádraig McGarry:
The Department of Health and the HSE have given clarification on what will happen. We are a negotiating body and we have negotiated all public contracts in the past 30 years. We should continue to do that.
Michael Harty (Clare, Independent)
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Is that the correct way to go forward?
Colm Burke (Fine Gael)
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Is anyone setting a timeline or will we be asking the same questions in three years' time?
Colm Burke (Fine Gael)
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On the progress in the contract negotiations. There is a ten-year timeframe for the plan on the future of health care and it will be difficult to develop that if we do not sign off on these negotiations. In previous negotiations between the Department and other groups it has taken a considerable number of years and I am concerned that this may happen again with GPs.
Colm Burke (Fine Gael)
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There is no roadmap at the moment.
Dr. Pádraig McGarry:
No, but one is being developed, which will show the priorities and will put a timeframe on when they should be implemented. We can talk forever but there need to be timelines for implementation. Even if the Department gave the appropriate resources to fund a fully-functioning contract and brought it in tomorrow, it could not be implemented because, as a result of the cuts of the past number of years, we do not now have the necessary capacity in general practice. It needs to be regenerated but the only way to do that is to produce a contract that is functioning, that attracts people and retains GPs who are currently choosing to go abroad for more attractive conditions. This will happen even more in the next number of years because the NHS will be looking for thousands and thousands of GPs and offering much more attractive conditions, right on our doorstep. It is urgent that we get this done. The roadmap should be brought forward to address that. We need timelines and matching resources.
Dr. Liam Glynn:
Senator Burke and Deputy Kelleher have got to the nub of this issue. If the majority of GPs are sitting outside this process looking in, the process will not be completed in one year, or two or three years. God knows how long it will take. If we agree on the importance of underpinning our new health care reform with a new GP contract we have to get serious about the process. Our stated position is that we want to get into the same room as the IMO, which represents the other element of general practice in this country, to work towards the development of a new contract as quickly and effectively as possible, so that everybody wins out. I wish the IMO had a similar position.
Billy Kelleher (Cork North Central, Fianna Fail)
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We are here to talk about capacity but if the contract is not effective we will still have a capacity problem because our GPs will still be going to Canada. The contract is crucial - it needs to be attractive for GPs so that it delivers for patients.
Dr. Pádraig McGarry:
The contract is absolutely crucial, as are all the supports which will be allied to the contract, and this is not just for general practitioners. The currency of general practice is time - the time to give to patients who present with increasingly complex problems as they get older. We are heavily dependent on manpower and because resources have been cut over the past number of years there is not the capacity within general practice to provide the necessary time. The resources are not there to hire people and most general practitioners probably have the workload of one and a half GPs and an additional nurse, but without the resources to hire. This will get worse because, as people get older, presentations are going to get much more complex and the time needed will grow exponentially. We need to address that.
Michael Harty (Clare, Independent)
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We will have an opportunity to come back to these points but we need to bring in additional speakers.
Dr. Brendan O'Shea:
These are very important issues and are very charged. We all have very significant performance anxiety over getting this right. There are several ways to go about it but we know, from examples in other systems which have carried out effective reform, that consultation is the way to go. However, our health system does not have that habit. We will probably not get it all right and we will get bits of it wrong. It is very important that the last paragraph of the contact stipulates that the contract will be reviewed again, not in 38 months but in 18 months. We need to think German, that is, we must have constant negotiation among all the partners including the most important, which is not the general practitioner, nor the pharmacist, nor the practice nurse, nor the administrator but the patient.
Bernard Durkan (Kildare North, Fine Gael)
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I have raised questions about the efficacy of primary care centres. They look very impressive and were very expensive but I do not know what they are supposed to do. The theory sounds good but I am not sure. My understanding was that they were to intercept patients before they crowded up the accident and emergency departments but it is not working out like that. They have state-of-the-art facilities but I do not know what is going to happen with them.
In the opinion of the witnesses, where did it all go wrong? I was a member of a health board and we all sat around a table once a month for a discussion. We made decisions and every issue was highlighted long before it became an emergency. A few years ago all GPs were listed in local newspapers as the highest earners in the country. Does the Chairman remember that? Where did that go wrong? Something happened in the meantime but nobody told me what it was, and I am a former Opposition health spokesman. Something happened within the structure of the service and that worries me.
The health services seem to be dumbing themselves down, or somebody is dumbing them down, to a huge extent and they are becoming demoralised. When a GP job was advertised recently nobody wanted it because the talk on the street was that the practice was about to close down and would not exist in five years' time. Who wants a job that is not going to be there in five years' time? Nobody. They were lucky, and delighted, to get one applicant but that person was not from the local area.
What is the problem with the delays in MRIs? What is the cause of that problem and what are the logistical problems with MRIs?
If one goes to a private practitioner in an alternative medicine practice one can have the result of an X-ray in ten minutes. If the X-ray is done in a hospital, one could wait for a long time, up to six months for it. All that delay leads to substantially higher costs.
I would have thought by this stage it would be possible for everybody to access diagnostics through the hospital IT system and the highest quality advice should be available. Why is that not happening? Where are we going wrong again? Mr. Chairman, we are talking about the people who are delivering on the ground. The first port of call will always determine what happens in the system.
My final point relates to an issue I was dealing with yesterday, which will arise tomorrow as well. There was a time a number of years ago when I used to be expelled from the Chamber for kicking up a row when questions about health were not answered. During the health board system, Members had got answers to all their questions and then following the shift Members got no answers at all. Members raise issues because somebody has raised it with them. A patient raises an issue with the GP because he or she has a reason for doing so. When we table a parliamentary question on the matter, we usually get a letter stating if the patient has suffered in the meantime or is facing increased levels of pain, he or she should contact the GP. They have already contacted the GP and the GP has made the representations in the usual way and nothing has happened. Why is that happening? Why is the system not responding? Delay creates problems for GPs and creates a backlog in the system. We need to invest in hospital beds, GP services, nurses and consultants and training. I am not so sure that we can invest all the money this requires all at the one time but I know we need to address the issue of waiting lists at accident and emergency departments as a matter of urgency. There is no sense in having a ten-year plan for that, it has to be done now and it does not require rocket science. From their vantage point, how would the witnesses solve this problem? The rest will follow. I know the Chairman is anxious that I stop.
Michael Harty (Clare, Independent)
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Unfortunately the Deputy has used up all Deputy O'Reilly's time.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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That seems unlikely, Chairman
Bernard Durkan (Kildare North, Fine Gael)
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Unlikely.
Michael Harty (Clare, Independent)
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I call Deputy O'Reilly.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I was struck by a statement in one of the submissions to the effect that proposals to address the shortage of GPs by transferring tasks to other health care professionals are not in the interests of patients or the State and then it continued with a list of bad things that might happen.
That flies in the face of the evidence and reports we have heard about skill mix and it ties into the issue of allowances for the employment of practice staff, which is raised in another submission. I have a number of questions on that. We hear from GPs about how pressed they are for time. I can see in my constituency that the patients lists for the GP surgeries are long and they cannot accept additional patients. I would not dispute for a moment that GPs are under pressure. I do not think that making such statements about nurses is helpful but that is a matter for the GPs. Would it not make more sense therefore if some of the business element of that were to be removed in terms of the employment? I imagine it is difficult to be an employer. I am not and never wished to be an employer but one ends up in that position. Many of the GPs I have spoken to would almost refer to themselves as accidental employers. They want to be doctors. They want to work with their patients and do not necessarily wish be employers. Would it not make sense to get rid of the allowance, the fee per item and all the administration that goes with it and have practice nurses and staff that are directly employed by the HSE? I was examining the figures from the primary care reimbursement service, PCRS, which outline the number of procedures and the number of claims. For every procedure I can imagine a rainforest worth of forms that have to be filled out to claim back the money. I do not attend a GP regularly but I know much of the work in respect of the fee per item claims is done by practice nurses. If that element of the work was taken from the work of the surgery, it might free up GPs to do what they do best, and what they trained for, that is, the hands on care.
I apologise for having been obliged to step out for a meeting, so if my question on diagnostics has been asked already, I will be able to read the response in the transcripts. I know from the parliamentary questions I have tabled and from the experience in my constituency that the primary care centres will be housed in lovely buildings but no additional staff are being employed in them. If the witnesses could design an ideal fully functioning primary care centre and could staff it appropriately, what would be the staffing model? What therapies would be on offer? What ancillary and allied health professional staff would be available and how would it function in terms of the machinery and equipment? In terms of a fully functioning primary care centre, would equipment, such as scanners and near-patient testing and so on be required?
In regard to the community intervention teams, CITs, what is the GPs' relationship with them? I understand that some CITs operate as a separate stand-alone resource and some are integrated. Will the witnesses tell members how the system operates across the country? Members will know how it works in their area but the witnesses might be able to give us an understanding of their relationships with the CITs.
I raised the question of blood tests with the Minister for Health yesterday. I understand there are issues with blood tests and I would like to hear both sides of the argument. My understanding is that medical card patients should not have to pay for routine blood tests that are part of the diagnostics. Yet I have seen notices in doctors' surgeries advising patients that if they are not prepared to pay for their tests, they should be prepared to take themselves to the local hospital to have the test conducted. Perhaps members could be enlightened as to what is the issue with blood tests. Perhaps that is tied into the issue I raised earlier.
Michael Harty (Clare, Independent)
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I thank Deputy O'Reilly. I call Deputy Kelly.
Alan Kelly (Tipperary, Labour)
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I welcome the witnesses. I apologise for being late. Unfortunately I am on two committees that sit at the same time on Thursday mornings, so I have to jump between the Committee of Public Accounts and the Joint Committee on Health. Like Deputies O'Reilly and Kelleher, I too am a member of the Committee on the Future of Healthcare, which is devising a plan for the next ten years. Politics has failed health in the past 30 years. There has been constant change, constant movement on strategy, geographical imbalances and not taking account of the demographics, as well as a range of issues. We need a timely and comprehensive plan for health.
I often find that the internal politics of health could actually give professional politics a run for its money. In fact in many cases I think it is worse, which is part of the problem. The internal politics of health are a significant issue. Somebody needs to bite the bullet and say it out straight. In the future of health care process, there is agreement - more or less - that there will be a period of transition and transitional funding will be required. Decisions are being made on a range of issues which cross over to the direction of the recommendations.
Obviously, the whole area of the GP contract is intrinsic to it. One of the best presentations given to the Committee on the Future of Healthcare was from a number of the hospital groups. One group CEO, Colette Cowan, said that in order to alleviate the issue she had in her hospital in Limerick the best thing to do would be to take away a whole pile of her budget and actually put it out into the community and primary care. That is the sort of thinking we need from everybody; someone who wants to give away a large amount of their own budget and someone who is willing to actually change the way they do things. The way in which GP practices are currently orientated is not right or correct. There is not a comprehensiveness with regard to service provision, geography or anything else. This is partly the fault of politics and the fallout of health strategy. It is also partly the fault of the GPs. Nobody is immune. Politicians are at fault, health professionals are at fault, health strategy is at fault and GPs are at fault.
The future of health is like a big jigsaw that is going to have to be put together. It is going to take a comprehensive period of time and a lot of political leadership over the next number of years. It is also going to take leadership from the individual bodies. We all know that with regard to the next GP contract, there were issues with what was previously left in place for a ridiculous length of time around its inflexibility and the way in which it was structured. I have had numerous conversations with many members of the representatives' organisations on this, especially over the past year. We are facing into a crisis given the volume of GPs who are about to retire, the demographic changes and the fact that we are not creating enough training places. That is all obvious and it needs to be dealt with quickly. I reflected on what my colleague Deputy Billy Kelleher said earlier that it is absolutely bananas for negotiations for the GP contract to go on without all of the representative organisations in the room. It is nuts. It shows that we have not learned anything and that we are going down the same road again. An action of this committee - that I hope the members will support- is to write to the Minister for Health on foot of this and make a recommendation that the negotiations are to include everybody. Otherwise the negotiations will then have to be continually reassessed. It is going to go on for years, and we do not have years. I hope the Chairman will take this on board, please, as one recommendation we should all make. My colleagues on the Committee on the Future of Healthcare will hopefully support that also.
On the requirement to create new GP training places, we need to be smart in this to correlate the fact that we also need to create capacity and volume for the other professionals needed in the primary care area - whether it is assistant GPs, practice managers, practice nurses etc. - because frankly, we need all of them also. That is an important issue. With regard to the new GP contract we also need flexibility in the type of contract in place. The contract does not have to be the same for everybody. The contract has to be fair and equitable but the same type of contract that operates in one location may not be necessary in other locations. There are many differences between urban and rural practices. There are a whole range of different factors that can influence that. We need flexibility, be it direct hire contracts or other types. There is one question, however, that I would like all six of the delegates here to answer directly. This involves a figure - I am a very straight talking person as everyone knows - and I do not want a narrative on this. What does a GP practising out of Dublin 16 expect to earn in one year in 2017? What would a GP working in County Tipperary, in example in my home town of Nenagh, or in Ballina or Killaloe in my constituency and the Chairman's, expect to earn in a year? Taking into consideration the costs etc., what would a GP expect to earn? The public would like to know that and I would like to know that so we can measure information during the process we must go through on the GP contract. What are the expectations of GPs? It is a critical question. Chairman, I am nowhere near finished. I have a serious issue with the timeframe on this, which I believe needs to be set out and shortened. I agree with the comments that were made on the requirements for community health, the integration of this with GPs, how they are operating and the diagnostics. I will not go through all of the topics because they already been commented upon. We also need to look at our capacity to bring in GPs from outside the State. Somebody needs to talk about this. It is unfortunate but there is going to be an interregnum where we are not going to have enough GPs, even if we were to solve this in the morning. There will be a period of time required for the upskilling and training of these doctors.
I would like to find out some statistics on how many doctors are actually not practising. How many GPs who are fully able-bodied and under retirement age - or around it - are not actually practising? Why are they not practising? What are the consequences of this in the areas where they are not practising, such as in Limerick? In the opinion of each and every witness here today, is it acceptable for GPs to bring in locums and pay them to run their practices? I would like the witnesses' opinions on this. In principle I agree with my colleague, Deputy O'Mahony, on the issue of the co-ops but I am beginning to wonder a little bit about co-ops. There are issues, which the Chairman knows about, in west and east Clare. With my health hat on I have an interest in them all but I am especially interested in the issue in east Clare because I actually use the co-op in Killaloe. I live on the Tipperary-Clare border, more or less. We had a situation where 12 doctors were involved in a co-op and two left, one retired and one moved to Limerick to fill a position - probably the issue I spoke about previously. The co-op's out-of-hours service reduced from 58 hours to eight hours. In that scenario GPs lose local support and local authority. The current GP contract, I accept, should no longer be in place and is completely out of date, but GPs have a responsibility for out-of-hours services because of this contract. That sort of behaviour is not good PR for GPs. Granted there are many issues there, but is it acceptable in the view of the witnesses?
I spoke earlier about the differences between rural and urban practices, the allowances available to doctors and that, for instance, there would have to be some form of allowances for certain costs. I understand that. Surely, however, they should be phased out over time? Have the representatives here today any comment to make on the whole area of pathway management to acute care? Pathway management to acute care is a critical issue. I live in a town, Nenagh, which has a minor injuries unit and hospitals in Limerick are bursting at the seams with the volume of referrals. I do not understand why the minor injuries units cannot take greater volumes than they currently do. This would alleviate the situations such as in Limerick.
It is very important that any future contract is managed. Any future GP contract would need to have a reporting system to the HSE and to the public, based around performance of GPs. For instance, without naming any names obviously, the management information would measure the volume of referrals each GP makes to an emergency department every month, week and year. When ambulance personnel come to me - and I will not say from what area or town - and talk about the volume of referrals in the same town from one GP versus another GP, it sets off alarm bells for me.
The demographics are the same as is the volume of people using each GP. Why, then, is there a difference? While there could be reasons, we have to find out. At least, with that management information, others could investigate. That sort of stuff needs to happen.
I am in complete agreement on the Carlow-Kilkenny model and the integration there. Do our guests expect that to be possible everywhere else around the country given the unique geography of some areas, etc., and the provision of the services available in those areas?
Dr. Karena Hanley:
We have just received a lot of questions, but they share a common theme. I cannot overemphasise the efficiency and productivity of a well-functioning, good general practice team. If this is also then embedded well in a primary care team, the potential to sort out a lot of these problems is enormous. We had such a lovely vision back in 1992 in the "Future of Health" document which described a really good way forward. Once again, there was talk about investing in primary care and general practice, but once again, it did not happen. Deputy O'Reilly talked about practice nurses and practice staff perhaps being employed by the HSE, but that fragments care. From talking to businesspeople, one knows that someone who is self-employed in his or her own business with a well functioning small business unit can increase productivity by 20% compared to State employment or a large, anonymous organisation. If one has practice nurses and practice staff employed by the HSE, that will increase fragmentation of care.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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In what way?
Dr. Karena Hanley:
They will not be attuned. One will not have unity of the practice message and one will not have unity of the practice objective and vision. That practice objective and vision must be to care for the patients. One of the unique things about general practice is that there is a mutual investment by both patient and doctor in a continuity of care over the years. This is a rich therapeutic problem-solving relationship which begins to really spin efficiencies as the doctors and practice nurses know their patients. There is a loyalty and a continuity of care. If one fragments that and loses that dedication to the general practice vision and objective within that practice, one will have lower productivity and worse outcomes than one has in the tight ship that a good general practice is.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I do not accept that. Changing the name on the payslip for the woman or the man who is a member of the practice staff would not, I imagine, in any way dilute their loyalty, commitment or ability to care for patients. However, it would alleviate a lot of what the witnesses tell us are the burdens of running a small business and all of that. I have spoken to GPs and one of the things they say to me is that they do not just care for their patients but are required to run a small business on top of everything else. A change in the name and handing the hassle to a big employer like the HSE, which has a payroll department and a HR department and all that goes along with that, while maintaining the ethos of general practice is a bit of a no-brainer given what GPs have told me about the nature of the business and the fact that it is very time consuming to run a small business. Taking some of that out, I do not accept would-----
Dr. Karena Hanley:
Having worked in a rural general practice for 25 years, I believe absolutely in the team model and in the independent contractor model. The problem is that the infrastructure has been hollowed out of general practice, which has made it very difficult to manage the escalating employer responsibilities, health and safety and so on. While all of these are coming to all businesses, there is no other business which has had its potential for income generation diminished in the same way as GMS general practice. That is why that is such a heavy burden. However, 66% of emerging GPs see themselves being independent contractors in five years. It is a model that has been proven to work and my experience is that it fosters the loyalty to provide a good service.
Michael Harty (Clare, Independent)
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How would salaried GPs fit into the context of general practice?
Michael Harty (Clare, Independent)
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If there were salaried GPs, there would most likely be salaried staff. Is that not the case?
Dr. Brendan O'Shea:
Through the Chair, we might go to some neutral territory. I practice in Newbridge where we have physiotherapists. We have some private physiotherapists in Newbridge and we have HSE employed primary care physiotherapists. For whatever reason, it takes six, 12 or sometimes more weeks to get an appointment with the HSE-employed physiotherapist. The HSE physiotherapist operates on a paper-based system. It is not easy to get on the phone to the therapist directly. The private physiotherapist can be contacted by text and e-mail and will see the patient the next day. The perception of patients, regrettably, is that the care provided by the HSE-employed physiotherapist is significantly less good than the care provided by the private physiotherapist.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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That is the patients' perception.
Dr. Brendan O'Shea:
It is deeply regrettable and it is the fact of the matter. It is difficult for us to criticise our colleagues in the HSE because we know many of them are passionate about what they are doing. We have a consensus among ourselves that the independent contractor model, properly resourced from 2.5% up to 8%, delivers efficiency.
I am moving on to another question, which relates to waiting lists and what can be done about them. There are 600 patients occupying hospital beds who are delayed discharges. If we had more capacity in social care and more community-based home-care packages and if general practitioners were enabled to do more in nursing homes so that they could build their function, one would suddenly have 600 expensive beds transferred to less expensive beds in the community. These are the things we believe will actually deliver efficiencies. We have 540,000 people on waiting lists. Most of them are on waiting lists for investigations. If we had access to those investigations, we could do them in general practice. We could do ambulatory care and keep these people out. In the same way that we have 600 delayed discharges occupying beds, it is a cause of huge demoralisation to us that we have to send people to these hospital beds while our colleagues in the NHS, in Perth and in Vancouver can do an awful lot more to keep people at home.
Going back to Deputy O'Reilly's question, I refer to Deputy Murphy O'Mahony's observation that co-operatives are in charge of 1 million consultations a year in the out-of-hours setting. They are delivered efficiently, quickly and powered by the independent contractor model that is run by general practitioners. That is efficiency. It is with deep regret that I note that the HSE has inherited a situation where it is in charge of enormous waiting lists. The co-operatives are the independent contractor model. Our practices are the independent contractor model. We did a very odd thing in the Irish College of General Practitioners, which was to carry out some research. We asked patients what they would like. We asked them what they would like in chronic disease management which is the big enchilada in all of this. We asked them if they would like consultant-delivered management of their chronic diseases or specialist nurse-delivered chronic disease management delivered in a hospital. We asked them if they would like nurse-delivered chronic disease management or GP-delivered chronic disease management. We collaborated with our colleagues in pharmacy on this study. We asked 600 patients, the majority of whom said they wanted GP-led primary care management of their chronic diseases.
There are some things we are not certain about. We know with respect to our health system that we appear to have more administrators relative to other more efficient ones. We know that they are paid a little bit more than in other systems. We know that they have managerial tools that are based on paper. None of these things is enormous, but they compound.
We guesstimate that over €20 billion is spent on payroll. We want more than 2.5% and we want that money to go into one of the most productive spaces, which is the interaction between clinicians and patients in the community. We want more care at home.
Dr. Emmet Kerin:
On Deputy Durkan's question regarding where it all went wrong in terms of primary care centres, what happened is an excellent example of us all working independently and in silos in the context of a strategy for the development of primary care centres, and GPs not being brought along with that process. When I established my practice in 2012, I was eager and keen in terms of my engagement with the primary care teams but I quickly found myself at 8 a.m. meetings that went on to 9.30 a.m. or 10 a.m. because of a lack of leadership and decision-making and meanwhile my patients were waiting for me. I was not resourced to be at those meetings.
Bernard Durkan (Kildare North, Fine Gael)
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Why did the meetings go on for so long?
Dr. Emmet Kerin:
One of the reasons was, perhaps, a lack of a senior decision maker. I am not as a GP making myself distinct from other colleagues in primary care but somebody has to take the lead. I see the GP, who knows the patient and the effect of decisions made at meetings on patients, as being that decision-maker. Also, there is replication of tasks, lots of note taking by hand with no IT support and so on. The point made by Dr. O'Shea regarding the private versus the public service in terms of physiotherapy is well made.
In terms of solutions, the National Association of General Practitioners has examined the issue of primary care resource centres, which is a move away from primary care centres. A primary care resource centre would be a service similar to the primary care centre but it would comprise the type of services required in individual areas. For example, services such as outpatient infusions for chemotherapy, removing blood for hemochromatosis, diagnostics, imaging and so on would be provided by the primary care resource centre but there would be no GPs in the centres. Instead, GPs would be linked to and have full equitable access to their services.
Bernard Durkan (Kildare North, Fine Gael)
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Why not have GPs in the primary care resource centres?
Dr. Emmet Kerin:
We have a hybrid of private primary care centres and HSE primary care centres but only a handful of GPs with access to them. The GPs that did not partake in the primary care centres strategy are effectively blocked from accessing them. In theory, they should have the ability to refer. If as a GP, I operate from an office down the corridor from a GP who has access to a HSE physiotherapist and I have a patient with acute back pain who needs help, the latter will probably help me. The corridor chat is perhaps the Irish way of solving issues. We need to move away from that to primary care resource centres to which we all have equitable access.
Bernard Durkan (Kildare North, Fine Gael)
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Is that not a duplication?
Dr. Pádraig McGarry:
The Deputy hit the nail on the head such that it would be a duplication of services. There are already in place structures to deliver services such as MRI scans and so on but they need to be scaled up to accommodate volume. There is no need to develop another structure to accommodate that volume. What is important is access to services rather than the geographical positioning of them. The process of providing access to MRI scans and X-rays online is very complex because these services are integrated throughout the country. Splintering that up into small hubs in various areas of the country will result in exponential cost. We need to expand the current service to accommodate the need. In terms of what is proposed, the result would be more groups seeking to gain income as opposed to an increase in patients' access. As I said, what is important is access. We need to scale up access. Where it is already in existence it is working well.
Dr. Austin Byrne:
In regard to the question of where it all went wrong, the answer is perhaps to be found in the question, when did it all go wrong? It all went wrong in 1973, shortly after the new contract was signed. We took the waterfall mentality of roll-out that is very common in public sector contract formation, namely, identify the problem and build current capacity around the need or demand while projecting forward. We cannot do long-range forecasting in health very easily. We certainly cannot do long-range demographic forecasting very accurately. We had a 1970s solution to a 1970s problem and as it rolled on it picked up baggage and excess need such that we currently have clinical unmet need patients who cannot access the services they need. Those patients, because they deteriorate in their clinical condition, tend to spill into services that are above their need.
We also have a huge layer of unmet need in terms of things we need to do that we currently do not do. In addition to GPs to man access to services for patients who cannot access them, we need GPs to man the services that we currently do not even consider to be GP services. As such, we have two layers of unmet need.
FEMPI came along in 2008. Reference was made to the glorious days of the wonderful salaries publicised in respect of GPs. My own practice was regularly listed in the top-ten earners, although towards the end of the list, unfortunately. It all looked wonderful. Included on the list were salaries of €600,000 for a practice in Tramore but that was a meaningless number, a top-line figure. In other words, the figure was the amount of funding provided to run the practice. Much was dependent on the structure of the claim system and the allocation of patients. In our case there were two doctors at the time and a third assistant. If the allocation of patients was weighted towards a single doctor in practice the list would reflect that in a single list number whereas there could be another practice equally-sized further down the road with three doctors but in respect of which the patient allocation, because the three doctors had opted to co-locate, was an equal split such that the payment to the practice was one third of that announced, or €200,000 per doctor, such that they would not make the list. Each doctor could be paid €205,000 such that there would be a higher total net top line income but they would not feature on the list. As I said, the list was meaningless. It should be borne in mind that that list represents top-line gross. For most practices, it would be necessary to take 50% to 60% off in terms of overhead costs and opportunity costs, such that the list would not be reflective of the true picture.
FEMPI destroyed us. The 38% cut in GP salaries was a top-line cut. Operating costs did not change. Patient demand and activity did not change. This leads me to the question posed earlier by Deputy Louise O'Reilly in regard to blood testing. Blood testing in the 1970s most people would agree was a rarity. Blood tests were generally done in an acute emergency. In other words, if a patient was bleeding, blood testing would be carried out to see if he or she had a bleeding tumour. That is very different to the role of blood testing these days and the role of blood testing into the future, which for Ireland, means enhanced near-patient testing. To suggest that a practice currently performing thousands of blood tests per annum should be offering those pro bonounder a capitation system that was never designed to fund them and does not fund them, is very difficult to square. I understand that among patients of lower income that is a barrier to care but there is an obligation on the health service - this was confirmed by Dr. James Reilly when Minister - to provide those blood tests in the local hospital setting. There is no similar obligation under contract.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Would Dr. Byrne accept that sending patients to hospitals for blood tests is a backward step?
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I have seen notices in GP surgeries to the effect that patients who cannot afford to pay for blood tests should seek to have them done at a hospital. Many of these people are patients who need blood tests and cannot face having to go to a hospital to have them done. How does one square that circle? My understanding is that the HSE is of the view that this is a service, regardless of the increase in demand, that is already being paid for. The person in the middle of all of this is the patient.
Whatever way one tries to square the circle, that is not fair. I do not believe any of the witnesses would be comfortable with the notion that people would call to their surgeries knowing they need a procedure but not having the cash to pay for it - the witnesses have reminded us that they are running a small business - and on seeing that notice on the wall deciding to take themselves home. People in the United States are having to make a decision as to whether they heat their houses, eat or get treatment. Patients in general are now making a decision as to whether they heat, eat of treat but that is not right.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I accept that challenge; they are turning themselves away.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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GPs are putting that notice up and making the position very clear. If a person does not have the money to pay for it, they can go to the hospital and if they cannot face the hospital they go home and worry.
Dr. Austin Byrne:
It does not arise that patients in acute medical need would be turned away. That would be intolerable.
It is also intolerable that the contract has remained in a 1970s state where these blood tests were simply not utilised for routine care in the way they are today. That needs to be addressed with respect to the contract formation.
If we reflect on where did it go wrong, if we consider patient numbers from 2006 to 2007, we had about 1.4 million patients and I am referring to medical card patients. That number grew over the intervening years to approximately 2.1 million. The 2.1 million patients in 2014 were funded to a total amount that was less than the funding for the 1.4 million patients in the earlier period. Therefore, demand grew but funding fell. Funding allows for time and time allows us to see capacity and therefore, it is all interlinked. It is a simple see-saw process.
Bernard Durkan (Kildare North, Fine Gael)
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The budget has been increasing all the time.
Bernard Durkan (Kildare North, Fine Gael)
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That is right.
Bernard Durkan (Kildare North, Fine Gael)
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That needs to be qualified-----
Dr. Austin Byrne:
-----by 40%. Let us consider patient demand and those complex patients who are on eight medications or more. These are people generally with diabetes, hypertension and complex multi-morbidities who attend hospital services if they are not properly managed with preventative care. Between 2004 and 2014, this cohort of patients rose by 300%. Therefore, the number of the most unwell in those ten years tripled and the demand for services among the most unwell tripled but the capitation remained fixed and, in fact, it fell off because of the financial emergency measures in the public interest legislation. The problem is one of contract design. We have an inflexible contract where all of the risk is on the provider and the purchaser gets off scot free. If we flip it on its head and consider the contract that exists in pharmacy for dispensing, all the risk is on the purchaser and the provider takes no risk. As we scale the amount of medicine dispensed, we scale the fee paid. When a patient is on eight medications, the dispensing fees are about 4.5 times the fee that is paid for medical care in the community. That is no fault of anyone but that is a fault of contract design and that is something that we need to look at very carefully.
Bernard Durkan (Kildare North, Fine Gael)
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Could we have an interim contract?
Dr. Brendan O'Shea:
We must have a rolling evolving contract. To return to an earlier point, we are not in the habit of having these conversations and we will just have to get good at it. It has to be an evolving contract. This is also a feature of more efficient health systems than ours.
To respond to Deputy O'Reilly's point, the blood test issue is very important. We have had a thousand difficult conversations with the patients in my small practice on this and it is utterly hateful. I was going to say the blood test is a symbol but it is about monitoring chronic disease. It is a matter of doing the test, making sure the results come back, communicating the results and perhaps altering the medication. Therefore, it is not just a blood test.
Dr. Austin Byrne's observation about the contract is correct. The contract we are operating is for the diagnosis of disease; not for the actual monitoring. It is really simple stuff.
An important issue that has popped up in two instances here is why general practitioners are not going into the primary care centres and there is also the matter of those doctors who are suddenly working much fewer sessions.
Dr. Brendan O'Shea:
It is a numbers game. Some of them are leaving. These are established GPs, tough resilient people like us, who are saying goodbye to it. That is beginning to happen. That is part of our 2015 crisis, but largely it is a numbers game. We need to move from having 3,900 GPs and 1,700 part-time practice nurses, arguably towards having 5,000 and 5,000 full-time, respectively. Thereafter, if we get modest amounts of money, we will be able to do the blood tests. Anything that one wants done will be done at a fraction of the price in general practice. It simply cannot be done for nothing.
With respect to why GPs are not going into primary care centres, arguably, there are not enough of them. A question was asked as to why we are not going to primary care team meetings, which are important.
Bernard Durkan (Kildare North, Fine Gael)
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Are they going to the them where they are located? We have a few of them in County Kildare. The question is: are they going into those centres?
Bernard Durkan (Kildare North, Fine Gael)
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Yes.
Dr. Brendan O'Shea:
There are not enough GPs. We are having difficulty getting them into our practices. Partly it is a financial issue and partly they do not want to have a thousand conversations with patients about not being able to do their blood tests. They are not going to explain to poor patients why they have to wait for six or 12 months for an MRI. That is what our younger colleagues are saying and the rest of us are pinned into the ground.
Another important point related to referrals and why some doctors refer more and some refer less. There is a huge evidence base around that.
Alan Kelly (Tipperary, Labour)
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Is it about timing?
Dr. Brendan O'Shea:
It is there and we know what it is. A common reason we refer more is that when one becomes significantly distressed and stressed, one's perception of clinical threat becomes higher. If one is working a 50 or a 60-hour week, doing paperwork out of hours and then going on to one's co-operative to do a four-hour shift and doing the same workload the next day and day after and worrying about the different issues with which one is dealing because there are not enough GPs in the practice, then one will tend to refer a little bit more. That is one of the well understood reasons we refer more.
Alan Kelly (Tipperary, Labour)
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I thank for Dr. O'Shea for at least being the first person to try to answer some of my questions, because I was beginning to wonder what was the point in coming in here. However, that does not stand up to scrutiny. I know of an example - I will not give the details as it would identify the GPs in the area - in which the practices are similar, the GPs are of a similar age and the patients who attend them have a similar demographic profile but yet one refers substantially more into a place in Limerick, a video of which the witnesses would have seen when 12 ambulance were pulled up outside it at one stage. Perhaps it was just a bad day but I am being told by ambulance personnel that this is a frequent occurrence. Dr. O'Shea explained what potentially could be happening but that management information, which is what I consider it to be, on those statistics needs to be churned and that needs to be examined or, dare I say it, investigated.
I asked a number of questions which have not been answered. They relate to what a GP practising in Tipperary would earn compared with a GP practising in Dublin 14 or Dublin 16. I referred to GP co-operatives, bringing in GPs from outside and management information, which I-----
Michael Harty (Clare, Independent)
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The Deputy also raised the Carlow-Kilkenny model.
Alan Kelly (Tipperary, Labour)
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If I get five of the ten answered I will be doing well. Those are the most important ones.
Dr. Emmet Kerin:
To answer a few of the Deputy's questions, an article was written at that time that 12 ambulances were pulled out outside University Hospital Limerick and subsequently there was a retraction from the UL hospital group, where the finger had been pointed at GPs being the cause of that. That has been retracted. It is very important to clarify that in Shannondoc, which is the out-of-hours service, there was a 7% referral rate to that hospital over the Christmas period. That is a metric that is audited and that is a fact. When we consider that sick people attend Shannondoc, a referral rate of 7% is tiny. What we saw with those 12 ambulances was the back-up, what was going on inside the hospital and the people in the ambulances were sick patients.
Alan Kelly (Tipperary, Labour)
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I agree. I have no issue with that.
Alan Kelly (Tipperary, Labour)
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No. I accept that point and I saw that clarification. I know all the individuals involved there. I have no issue with that. There is no issue with the majority of GPs but we need to know if there are substantial differences and, if there are, why there are, and they have to be explained. If they are explained that is fine, but currently they are not explained.
Billy Kelleher (Cork North Central, Fianna Fail)
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It is also shown in research that the further one lives from a hospital, the less likely one is to be referred to a hospital. There is research supporting that. The nearer one lives to a hospital the more likely one is to be referred to it. A person from Castletownbere in west Cork is not as likely to be referred to Cork University Hospital as a person from Bishopstown who lives close to that hospital.
Dr. Liam Glynn:
A version of general practice which I do not recognise is being created by the committee. I am a rural GP and will return to work a Shannondoc shift tonight. I will cover west Clare, from the Shannon Estuary to Galway Bay. Deputy Alan Kelly correctly identified the changes that had occurred in Shannondoc, which I completely agree have been extremely regrettable. The only area about which I can speak is west Clare where five years ago there were 20 doctors working, but now there are 15. We have lost 25% of our workforce. Therefore, it is not possible to provide the cover we once provided. It would be fantastic if we could. To me, this is the perfect symptom of what is going wrong, which is that we cannot get GPs to work in rural areas and urban deprived areas.
Examples have been given of practices which have no applicants. I know of a practice which advertised a vacancy in Naas, a commuter town which one would perceive to be well off, but no one applied. This is happening across the board. I am particularly aware of the problem in rural areas where there are real challenges. There are increased poverty and deprivation levels. There are also increased age levels which are associated with the multi-morbidity described. We go to work every day to try to keep our patients away from hospitals. I echo the statistics mentioned. We simply cannot get people to fill posts. It reflects what young GP trainees think about their future being in this country. We need the contract badly because there is a complete lack of certainty about career progression. If we could provide the contract, perhaps we might provide certainty and be able to bring back the cohort who are already abroad.
People spoke about locums running practices, but we cannot find locums and even if we could, we would not be able to afford them. There is huge variability in the general practice model throughout the country such that we need to take the differences into account.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Is that the key to the contract negotiations? The contract is not fit for purpose because it does not recognise current demand and that the delegates are interested in the negotiation of a contract that could be reviewed and would be responsive to patient needs. I am a trade unionist, as the delegates know, and I absolutely respect their right to be represented collectively, but sometimes I think GPs do not do their own cause any favour because they come across as small business people and that this will not help them. What they are saying is they are interested in a contract that would be responsive to the needs of the patient. I have views on what it might contain, as do the delegates, but that is where they are at in the negotiations.
Dr. Karena Hanley:
It is wonderful to see that our message is getting across. Deputy Louise O'Reilly summed it up really well, for which I thank her.
I will take up the issue of a variance in standards between doctors, to which Deputy Alan Kelly alluded. The ICGP has a great interest in raising the standard of general practice. The evidence shows that one of the most effective means of raising standards is by giving feedback on prescribing rates for benzodiazepine and antibiotics. If there is a problem with performance, feedback on average performance is the best way to improve and change behaviour. The ICGP is poised and ready to deliver this feedback with the Irish primary care research network, but we need a little more investment. The project has stalled because of a lack of funding, but the ICGP is poised and ready to be very effective in this area and provide solutions.
The question was asked how many GPs were not practising. The TCD study tells us that 76% of all GPs are full-time. They work eight clinical sessions a week and have another three devoted to paperwork. There is evidence that these GPs work 60 to 70 hours a week and then provide an out-of-hours service.
Alan Kelly (Tipperary, Labour)
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What about the other 24%?
Alan Kelly (Tipperary, Labour)
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Is there a percentage who do not work at all?
Alan Kelly (Tipperary, Labour)
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That is useful information to know.
Alan Kelly (Tipperary, Labour)
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Fair play to Dr. Hanley; she is the first to address it.
Alan Kelly (Tipperary, Labour)
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What is the figure?
Alan Kelly (Tipperary, Labour)
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I am genuine about this. From Deputy Bernard J. Durkan's question, I understand how the figures from years ago were broken down because it was a top-line figure that did not explain anything unless it was broken down. The question I have asked is very simple and the reason I am asking is not to stick anyone to it. We need to know what GPs' expectations are with regard to staying in or leaving Ireland after completing all of their training. There are costs associated with living in Dublin, County Tipperary or County Clare. I am asking for a ballpark figure. It would give an understanding or set a concept for us and the general public.
Dr. Karena Hanley:
I will give the Deputy two good mechanisms to be used in arriving at the figure. The first is to think of any service provider in the State who has expertise and invested a huge amount of time in training to get to a certain point and has the full gamut and range of responsibilities of a GP. The second way to arrive at the figure is through international evidence on primary care services which suggests that to have a strong primary care system GPs should earn at least 80% of the salaries of their hospital consultant colleagues.
Louise O'Reilly (Dublin Fingal, Sinn Fein)
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We finally have the figure. With regard to-----
Michael Harty (Clare, Independent)
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I have one more contributor to bring in. I want to include Senator John Dolan in the questioning. We can come back to all of the issues raised.
John Dolan (Independent)
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I thank the representatives of the three organisations, whose input has been helpful. It is quite clear after two hours of questions, observations and comments that this is a massive issue which we have to work our way through. We are here to speak about issues related to general practice manpower and capacity and a properly functioning primary care service. Clearly, the contract and from where the money comes must be part of the discussion, but it must go beyond them.
Representatives of two of the three organisations spoke in their initial presentations about chronic conditions, illnesses and diseases and the role of the GP. I want to focus on this issue, in particular. My particular interest throughout my working life has been people with disabilities and meeting mental health needs. I have worked with the entire gamut of organisations. People with chronic conditions do not account for the majority of the population but they certainly account for the majority of users of the system. Huge improvements have occurred in the past two decades in the longevity of people's lives. Morbidity is one of the legacies as regards what happens to people who do not die earlier, to put it as crudely as possible. I have several questions, but I will triage them and keep them brief.
All of us - the joint committee and everyone else with an interest in the issue - must consider how the groups and organisations that support and represent people with a range of conditions can gain direct access to what we will try to fashion. This relates to the first question I will ask. Members will be aware that there are support organisations for people with particular conditions, for example, Alzheimer's disease, stroke or muscular dystrophy, and people may or may not know about these groups depending on whether they have an early diagnosis and so on. These organisations have a role to play. I wish to address the issue of self-management. In the past decade or thereabouts, I have seen people with certain conditions going through programmes independently and this has given them a better sense of control, ownership and leadership over the condition with which they and their families are struggling. Dr. Byrne spoke about passing down units of activity. In a sense, what I am speaking about is passing units of activity and partnership down to the person who has a chronic condition and his or her close advocates, for example, a family member. How can that become a richer part? We have many groups, some stronger and more competent than others, associated with various chronic conditions. These conditions are being diagnosed earlier and people are living longer. I ask witnesses to give their initial observations on that.
Will the witnesses name one or perhaps two actions, changes, developments or obstacles outside the health system that have an impact on health and welfare? We spoke about inside the health service but there are other parts of people's lives and public services that have a bearing on how fit, competent and supported people can be in dealing with various eventualities.
Michael Harty (Clare, Independent)
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I will add to Senator Dolan's comments. While the Committee on the Future of Healthcare and this committee are different forums, many members sit on both committees. We have a once-in-a-lifetime opportunity because the health service is at a critical point and we have an opportunity to promote change. This will be done in the report to be published in the coming months. We must move in the right direction because if we head off in the wrong direction, the health service will be dead in the water. We also need to assist the Minister and Department to move the health service in the right direction. One of the core findings of the committee will be to recommend a shift from hospital-centred care to primary care, community care and general practice, whichever way people may wish to describe it. As the witnesses stated, general practice does not have the capacity to take on additional work because the system is on its knees. What are the fundamental triggers that would bring about change and help us to move in the right direction to build a service based on community care?
John Dolan (Independent)
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I was referring to the health sphere.
Dr. Pádraig McGarry:
The Senator hit the nail on the head. One of the biggest issues facing us all is the ever growing obesity problem. Education on diet, exercise and so forth should be provided from childhood onwards, starting in crèches and schools. This would make a major difference if implemented properly.
I have a model on my desk for nicotine replacement therapy. It is a cube which contains tar and when turned upside down, thick tar drips downwards. It shows the amount of tar deposited in one's lungs after smoking 20 cigarettes per day for two months. Every child who comes into my surgery is transfixed by it and they all find it disgusting. This model should be in every classroom in the country because it has a visual impact on children. We should create something similar for alcohol and diet to be shown to children at a very early age because they feed off teachers. If a child's teacher says something is right, he or she will think it must be right. Unfortunately, there is a major deficit in this area. This is one simple thing that would have an impact across the board. I know it would require an investment over years but it is one issue that would hit home. It is an example that stuck in my mind and one which could be done.
Dr. Liam Glynn:
I fully agree with Senator Dolan on the burden of morbidity associated with increased life expectancy. I have been examining this issue in detail in my academic career, focusing particularly on self-management. This is a major element and almost an elephant in the room in the sense that we do not talk about it nearly enough. My particular expertise is in high blood pressure and physical activity. It is clear that if we enable patients to monitor their blood pressure, it has a benefit in reducing blood pressure by almost the same amount as one of the medications patients take. This practice has a very powerful effect and I am delighted the Healthy Ireland strategy places emphasis on this type of approach. It has been shown clearly that brief interventions by general practitioners are extremely effective in encouraging lifestyle changes. However, such interventions require time and general practitioners are running to catch up with ourselves. If this could be enabled, it would be a very powerful mechanism for dealing with much of the morbidity we are experiencing and would genuinely empower people to manage their conditions. Not only does this benefit the individuals in question but it also benefits the health service.
In terms of actions outside the health service, I very much agree that obesity is only one of a number of the health tsunamis on the horizon. In many ways, the obesity tsunami has already struck. The National Association of General Practitioners very much supports the idea of a sugar tax. This measure could be very effective. We have also expressed public support for minimum pricing for alcohol. The alcohol Bill before the Oireachtas is important because general practitioners see day in and day out the detrimental effect alcohol has on lives.
Dr. Brendan O'Shea:
As the time is winding down, I will keep my responses brief. On Senator Dolan's question on how we can get people more involved, the Irish College of General Practitioners has grappled with this issue for some years and we recently agreed an approach for 2017. We intend to establish a process in which we will approach some of the larger voluntary patient organisations to ask for assistance in identifying representatives of the public interest for appointment to our committees. We have some experience with this approach, which we regard as necessary and of vital importance, although it is also difficult, complex and challenging.
At practice level, I suspect that if Dr. Glynn were not here this morning and did not have to rush down to do an on-call shift and probably deal with some paperwork on his way, he might have more time in his practice to formally engage with the people who come to his practice. This means doing practice-based research, including on patient satisfaction, and meeting more patients, not in the context of their illness but in terms of, "This is our practice and what will we do about it." This brings us back to the issue of numbers and manpower. We need more general practitioners and nurses. If we get 5,000 general practitioners and 5,000 practice nurses, we will be able to operate earlier on in the life cycle.
To return to the question on what we could do that would make a difference, although we are spending enough money, we are spending it too late in the life cycle. I strongly concur with Dr. McGarry's observation in this regard. It is an educational and health care principle that the return on every euro spent on education in the first five years of life is €20, whereas the return on euro spent in adolescence is €4 and there is very little return for every euro spent on people aged in their 20s.
The same applies in health care. Understandably, we are spending a large amount of money on hospital-based care, on the care of advanced disease and on the complex co-morbid patient. We want to be able to deliver high-volume brief interventions in our practices. There is a strong evidence base for this when it comes to smoking and people who are overweight, but it is simply not getting done. We need to focus where we are putting our spending. We are asking the committee to bring us in line, up from our 2.5% closer to the 8% figure. In England, with Brexit and so on, they are going to a figure of 11%. We will deliver better value for money with our independent-contractor model.
Billy Kelleher (Cork North Central, Fianna Fail)
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I am unsure whether my question goes against the general principle of general practice. Let us extrapolate manpower assessments, requirements and needs in conjunction with demographic trends for the coming years and the associated health needs. Reference has been made to obesity, but the key issue is the ageing population as well as chronic illness and disease. Let us suppose we have an extra 1,000 general practitioners. Is there not a role for some specialists within general practice? I have in mind GPs specialising in certain areas within practices to deliver front-line care in the GP setting. For example, my GP is a former surgeon. He loves ingrown toenails and so on. Other GPs will not perform those procedures to the same extent. Is there a possibility for specialty work within practices, whether respiratory, chronic or whatever?
Colm Burke (Fine Gael)
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It is obvious from listening to the deputations this morning that the new contract is somewhat down the road. I am concerned about the disconnect between GPs and hospitals. Deputy Kelleher referred to the Kilkenny model. Is anything being done to try to improve the connection in other locations? Such moves do not seem to be under way. As a result, GPs cannot get advice from the people further up the line. This needs to be fast-tracked now. As I have said, it seems we are somewhat down the road from a contract. Therefore, the question arises of how we deal with it in the meantime.
I met some junior doctors with the National Association of General Practitioners. One point that came across from the meeting was the lack of confidence on the part of GPs about the extent to which they could make a living by being a GP. One suggestion thrown out was the question of four or five sessions in hospital. That would cover at least some costs. Recently, I spoke to a GP from Canada. She goes to the hospital and does four three-hour sessions per week there. She has a direct connection with the hospital and the GP practice. We do not seem to have this type of cross-over. The emergency consultants were before the committee last week. They maintain it is happening in some hospitals. However, it is on a small scale. Is this something we should try to develop?
Dr. Brendan O'Shea:
These are important questions. I will address the question about GPs with a special interest: life is a bowl of toenails. Some of them attract perverse incentives for removal. Let us suppose I send one of my patients to a private hospital. The cost of the procedure by billing through private health care will end up in the order of approximately €500. This includes a greater fee for the surgeon and there is an anaesthetist on stand-by in case anything goes wrong in a clinic room. If I do it for a patient under VHI cover, it will cost approximately €80 or €90. If I do it on the medical card system on the public side, the public patient gets the thin end of the wedge and the cost comes in at approximately €38. Therefore, I cannot do it for the public patient. That was twisting me up inside, so I stopped doing them. We have carried out surveys of the members of the college. Approximately, one quarter of our GPs are keen and interested in developing special interests. A doctor with an interest in diabetes in a four-doctor practice could really lend an edge. It is a question of manpower: we are short of the doctors to do it.
I will move on from toenails. The next question was about the disconnect between hospitals and GPs. We are working on this. We know what we need to do.
Those of us going back to busy surgeries need to be able to engage. We are looking at local integrated care committees. This can be done elsewhere. Part of it is a question of manpower. It is difficult to get out of our surgeries. The minute anyone leaves the surgery, the practices immediately start running at a loss in a material way. It is not only a financial thing. Patients need to be seen. We need more doctors and practice nurses who can do work we are doing at present.
We know what needs to be done. We have had different people looking at our system. I am keen to highlight one of the observations. It comes back to the point about the chaos outside University Hospital Limerick and the ambulances. One issue is the gap at regional level. We work hard in our surgeries. Our specialist colleagues in public hospitals work appallingly hard in the public hospital system. We do not have the mechanisms to integrate on a system-wide basis. There are isolated examples. Everyone refers to the arrangement in Carlow and Kilkenny. The consultants and GPs there put in the extra hours to put something in place and they got funding for it.
Much of our funding at the moment is delivered in a manner that is exquisitely sensitive to budgets. It is control-centred. An overview of our system suggests we need more autonomy in regions, towns and villages. We need more direct involvement with clinicians. However, for that to work, we need more clinicians.
Dr. Emmet Kerin:
I will address the question from Senator Colm Burke on local integrative care committees. The arrangement in Carlow-Kilkenny is the shining example and it is often referenced. That was a long process. I have been there and I have examined the model. I have tried to get something similar established in Limerick. One theme that came out related to trust and relationships. The building of trust and relationships has to be organic. This is difficult when people are under pressure and are facing cuts. It is also difficult for GPs operating in marginalised areas that are no longer feasible. There is a level of hurt and mistrust between the departments and the HSE. We need to build that up. It happens slowly over time. I will summarise a theme that came out today on the contract side. It relates to what Deputy Kelly has said about the joint committee writing to the Minister to make this happen. The message for the Irish Medical Organisation is that there is a need to work at the same level and that building the contract together is better.
Dr. Austin Byrne:
I wish to address Deputy Kelleher's question about sub-specialisation. There is definitely a role for it. That has been internationally proven. Efficient high-volume turnover is the key. A certain volume of procedures need to be done to a certain standard. The difficult is the current manpower deficit.
I will make a brief comment on the salary question referenced earlier by Deputy O'Reilly. I would collapse at the thought of my practice nurse becoming a HSE employee. I realise that may sound abrupt, verging on rude. However, we know from looking to the public sector that levels of efficiency are perhaps well under half of what they are in the independent contractor sector. We know levels of sick leave are approximately four times higher. We know that public health nurse visits probably cost the State approximately nine times the cost of funding a practice nurse visit after we factor in all the associated costs. Moreover, we have a barrier to innovation. If I want to change something, I have to refer up to national level. Things can only be done on a national level. There are barriers to local changes to meet the needs of the individual community and small pockets of people. It is a fine idea to try to separate us from some of that workload, but I do not believe it will happen.
Deputy Kelly was mad for a number. Am I going to give him a number? No, I am not.
Alan Kelly (Tipperary, Labour)
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I am not that mad for many things in here. Perhaps I am just mad.
Alan Kelly (Tipperary, Labour)
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I asked the question for the purpose of trying to keep people there.
Alan Kelly (Tipperary, Labour)
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They vary as well.
Dr. Austin Byrne:
They vary in the public sector. However, we can get a good benchmark from international figures. We need to look at what is available elsewhere in the world. Furthermore, it is not enough to say that a doctor is being paid a given amount. We have to consider the workload relating to families, other paperwork, after-hours care and 24-7 on-call liability.
Alan Kelly (Tipperary, Labour)
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As Deputies, we could make the same argument.
Billy Kelleher (Cork North Central, Fianna Fail)
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There is work for most of us.
Alan Kelly (Tipperary, Labour)
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We have to carry out this work in a genuine manner. It is part of what has to be done. Someone has to do it. Ultimately, it may not be possible to do it here.
Alan Kelly (Tipperary, Labour)
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Somebody will have to set a range, otherwise while it is going to be agreed, it is going to miss the target.
Alan Kelly (Tipperary, Labour)
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I am not talking about overheads.
Alan Kelly (Tipperary, Labour)
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I already acknowledged that.
Dr. Austin Byrne:
That is the difficulty there.
I see the salary for general practice as a niche phenomenon. It is very difficult. The model sounds attractive in rural and deprived areas. It is going to be next to impossible to implement because the associated costs and overheads will more than double the cost of service provision. I can provide numbers for that later. It is really tricky for a public health service to provide that.
Michael Harty (Clare, Independent)
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That would be helpful.
Dr. Austin Byrne:
I think the corporate sector would love it in the morning, in leafy green suburban areas. They would lap it up and we would be sold a pup. Similarly, on the IT side, the notion that tele-medicine is going to revolutionise general practice is not going to happen. It accommodates and facilitates the patient movement. It relocates the interaction. It does not shorten the interaction. It does not provide better outcomes. It does not provide safety. It is largely rolled out on behalf of providers to add an additional value added layer of profit.
Michael Harty (Clare, Independent)
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I thank Dr. Byrne.
General practice is going to be the foundation of our new health service if we can transform our health service into a new health service. The evidence given this morning is extremely important and will be built on. I think we will revisit it in the not too distant future. What is the one trigger the witnesses could see that would trigger a change from a hospital-based, hospital-centred service to community-centred services?
Dr. Karena Hanley:
One thing that is important is that we have spent the last 15 years hearing, time and time again, how the future is primary care and how general practice is a linchpin. A 2014 Oireachtas report described it as the linchpin of primary care. We have heard talk about shifting resources again and again and we have experienced the reverse.
Michael Harty (Clare, Independent)
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And the trigger?
Dr. Brendan O'Shea:
I concur with my colleagues. Properly resourced general practice contracts are probably the biggest game changer. I think many other things will follow on from that. We will be able to retain our trainees. We will get the complement up. The independent contractor model as it is will enable us to involve more practice nurses. We will be able to do more in villages and communities. We will be able to go into nursing homes. We will be able to accept patients from the acute hospital system and if we get diagnostic firepower then we will not have to send anything like as many into hospital. Then we will be on to a winner.
Dr. Austin Byrne:
I would go a layer beyond resources, which we absolutely need but we must be very careful how we choose to deploy the resources. Our traditional contract model deploys resources in a capitation based method. The Organisation for Economic Co-operation and Development, OECD, has warned against this in the past year. We need to ensure that resource flow follows activity, complexity, efficiency and with quality as the underpinning factor. Move it down the value chain to the most competent area at the highest, most appropriate level of expertise. We tried it in the past and we said closest to the patient and we spent an awful lot of money building white elephant centres to relocate staff with no additional activity. We need to be careful not to replicate that.
Michael Harty (Clare, Independent)
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The trigger, Dr. McGarry?
Dr. Pádraig McGarry:
I will repeat and echo everything that has been said here. It has been said that resource allocation to primary care and to general practice has been promised and the reverse has happened. The consequence is the crisis that faces us now. We have pointed out what the problems are. They have to be addressed and solutions have to be created. The solution is to resource general practice adequately, to bring back people who can deliver for patients.
Dr. Emmet Kerin:
I think that we all agree on the same points. I quote the director general of the HSE, Mr. Tony O'Brien, one cannot build a service on fresh air and goodwill. I think he has clearly pointed out that there needs to be transitional funding put in. That is the trigger and the mechanism to achieve this. We need to underpin it with a fit-for-purpose GP contract.
Michael Harty (Clare, Independent)
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On behalf of the committee, I would like to thank the witnesses for their attendance and wholehearted engagement. I hope that we will revisit this area again because it is going to underpin the future of our health service.
Alan Kelly (Tipperary, Labour)
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Can we have five minutes in private session after the guests leave?
Michael Harty (Clare, Independent)
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If the Deputy wishes.