Dr. Emmet Kerin:

We wish to thank the committee for inviting us here this morning to discuss primary care expansion as recommended in the Sláintecare report. I am the president of the NAGP. I am also a Limerick-based, full-time GP. I am joined by Dr. Ronan Fawsitt, a Kilkenny-based GP, and Dr. Mary Flynn, who is based in Wicklow, who are members of our executive. I am also joined by Dr. Maitiú Ó Tuathail who represents GP trainees within our organisation. Those trainees are effectively the future of our profession.

Some time has passed since we last met in February. At that point, we were addressing capacity and manpower in general practice. We had a very valuable interaction with the committee in conjunction with the Irish College of General Practitioners, ICGP, and our sister union, the Irish Medical Organisation, IMO. I wish to acknowledge the committee's work at that time to support the introduction of a new GP contract through its request to the Minister of Health, Deputy Harris, to have parity of process in contract negotiations for all the representative bodies. There is great synergy to be had in all three organisations working together. It is the stated position of the NAGP to be inclusive of all bodies in this process.

Based on our earlier presentation and the supporting documents we have submitted, particularly the document submitted from the perspective of GP trainees, the committee is pretty well informed now of what the issues in general practice are and what we continue to face. We need to retain young graduates and restore functionality. It has become very clear to the committee that functionality needs to be restored in general practice. We clearly need a solid foundation if we are going to make any transitions in health reform. This view was confirmed by the HSE-commissioned report, A Future Together, compiled by Trinity College Dublin. In that report, Professor Tom O'Dowd says:

Providing long-term illness care, improved diagnostic services, increased practice based staff and modern IT requires additional funding. Primary care and general practice, as now structured, will be unable to cope with additional workload. Transitional funding spread over a number of years is needed ...

That is becoming more and more clear as we have these discussions. Today we really want to focus on what the key enablers for primary care are and also to reflect on the Sláintecare report itself. The NAGP’s position at the time of the launch of Sláintecare was to support the core principles within the report. We continue to hold that position. We can all agree the report is certainly visionary and outlines a paradigm shift in how we deliver health care in this country. However, until such time as general practice is adequately resourced and has a totally new contract, this will unfortunately remain only a report. General practice, through the contract, underpins an effective primary care service.

The recent report to which I refer places the general practice service as one of the key enablers in the move to a primary care model. This report and other bodies use the term “GP-led primary care”, a term which has been one of our core principles over a number of years and which is our message in the conversation on health care reform. For clarity, the GP-led aspect does not make general practitioners superior to other members of the community team. It identifies a leadership role in the team with responsibility and accountability for delivering care to the patient. This is called governance.

There are many existing team-based models of care in the world that demonstrate GP-led primary care, leading to better health outcomes for populations and greater return on health care spend. Examples are the patient-centred home care model seen in the United States, the New Zealand primary care health system, or the rapidly emerging primary care home model in the UK. The NAGP recently led a delegation to Plymouth to study the principles of such a model. These models are not directly transferable to Ireland but the core principles certainly are.

Data are driving change across the world in health care delivery. Ireland has recently made good progress through Health Atlas Ireland, which can now map local population demographics and health needs. This is very important for population health planning. Similarly, the national quality assurance and improvement system is leading change in the hospitals. It drives investment and service delivery for local populations, building integration and support through GP-led primary care.

This is a lot of change. With change comes fear of change, and with that the potential for misinformation. We have experienced that ourselves while discussing these models.

The reality is that GP-led, team-based care, involving personalised care for a defined population, is a culture change that comes from grass-roots level and not by diktat. It is informed by international experience but does not seek to copy it, merely to learn what works and apply this, if appropriate, to the Irish system in an agreed, resourced and beneficial way.

The Sláintecare report has recommended an impact study on the effect of separating private practice from public practice at secondary care level. It is only logical to have the same approach to considering the implementation of free GP care. The Minister for Health has acknowledged the GP service is put to the pin of its collar and pointed out there are lessons to be learnt from our experience with the introduction of free care to the population under six. We have already seen from the under-sixes provision the effects of what we call "service-induced demand" on a GP system that lacks capacity for the increased activity that free GP care has brought.

The Government-funded and Government-partnered ESRI study Growing Up in Ireland shows there was a 25% increase in daytime activity with free GP care. That predates the introduction of the under-sixes initiative. With free care for the under-sixes, we have seen an increase of up to 40% at peak times in our out-of-hours service. I am from the mid-west, in Limerick. The Shannondoc out-of-hours service crashed owing to the volume of calls over the winter. It is interesting to note that. The knock-on effect has been increased waiting times for all patients and reduced access for the frail elderly in general practice, with increased attendances at emergency departments. Therefore, there are consequences.

We suggest that we hit pause on introducing further free GP care based on age cohorts and start to make general practice functional again as a foundation for delivering real health care reform. We suggest that for primary care to expand into population health, as outlined in Sláintecare, general practice must first be stabilised and enhanced through positive State actions in the areas I shall mention. There is a lot of overlap but I will run through the areas again.

We need to reverse FEMPI. This must be in line with health care workers. This must not be delayed until 2019 to seek more return because there is already a stretched service.

I touched on the contract. It has to be totally new, not one with a bolted-on element. It should not be delivered in incremental phases. We need a new contract and a new way of delivering health care. We need to move from a sickness model to a wellness contract. That is the big difference here.

We have touched on capacity from a trainee's perspective. Dr. Ó Tuathail will refer to this later. We need to increase capacity, including through novel ways to utilise practice nurses and other allied health professionals in the community, with the general practitioners driving the change.

With regard to data and ICT, funding is absolutely necessary. General practice does have fairly good practice-based systems but we need to have connectivity to bring us together. Diagnostics was well covered. We can agree on that. Funding needs to be front-loaded, ring-fenced transitional funding, underpinned by legislation over a ten-year window to support primary care development. We must spend if we are to save in the long term. On implementation, general practice should have a role in the Sláintecare implementation body.

All these measures require funding and a strategy. Most of all, and important to those in this room, we need the political commitment to drive the change. We suggest all this needs to be underpinned by legislation, facilitated in the Oireachtas.