Professor Tom O'Dowd:

The report concerns more than clinical pharmacy. I presume Deputy O'Connell addressed clinical pharmacy because of her background. "Clinical pharmacy" is a bad term. The report deals with community pharmacists but, in hindsight, practice-based pharmacy should probably have been included.

I take Deputy Kelleher's point about people going to pharmacists in regard to minor illnesses, many of which can be treated with very cheap medication. However, if a pharmacist stocks a medication that he or she wishes to sell or on which there is a good margin and so on, that introduces conflicts of interest. Retail pharmacists have to face such conflicts of interest, which is why the NHS has moved towards practice-based pharmacists who are not involved in the retail end of the business. This cannot be dismissed as only occurring within the NHS. In my practice, we have appointed a clinical pharmacist whose first role is to conduct a brown bag review. The patient brings in his or her medication in a brown bag and the pharmacist goes through that medication. This takes time but is very important because there are some medications of which people are very fond, such as sleeping tablets, and others that they do not take, such as diuretics, perhaps because they are going into town and do not want to have to rush to a toilet.

There are many kinds of sophisticated, yet quite simple, approaches to doing that. There is also the fact that many patients are on ten or more medications.

The most dangerous work that I do as a GP is repeat prescribing. It is an absolute burden and a medical and legal minefield. I sign these things at speed, yet there are medications that interact. We have disabled the interaction alert on the computer because it says that everything interacts. Some sort of common-sense approach to this issue is necessary. We should ask the patient if they are coughing or falling over when taking these medications. That takes time, and it cannot be done in a retail pharmacy. It is confidential work, particularly when it comes to older people. They do not want to be standing in a shop with a queue of three or four people behind them and telling people that they are having various side effects from medicines. It cannot be dismissed just like that. The safety issue with medications is now quite important. One in three people has a reaction to a medication. It could be anyone. As people get older, clearly the number increases.

Access to diagnostics was brought up by a number of members of the committee. This is a real problem. I am better qualified medically than some of the people to whom I refer patients, but I cannot get access to diagnostics. It is bad medicine if I cannot access diagnostics. The situation is poor. Deputy Kelleher asked where diagnostics should be located. We have developed a new centre in Tallaght with a 5,000 sq. ft area into which we are going to put diagnostic equipment. In choosing what diagnostic equipment to install, we have stayed away from radiology because it requires so many health and safety precautions, including lead lining. We are installing ultrasound, DEXA scanning and MRI equipment. There is a lot of footfall in this area. The ideal situation for us would be if some of the radiologists from a local hospital would take an interest in it and take it over, and if extra resources are required they should get them. There is no doubt that patients, especially as they get older, find hospital access and traversing the hospital system very difficult. There is also no doubt that once our hospital colleagues come out into the community, it rearranges their heads and they begin to see people who are dressed like normal people, who have views and opinions, talking about politics or the price of things. It humanises them, whereas many of our hospital systems, sadly, dehumanise people. Diagnostics should be located in an area which serves a number of practices, not just one. It is a community approach which stays away from the dangerous stuff, such as radiation.

Deputy O'Reilly asked a number of questions. I must say that workforce planning is what I would call a dark art. I am quite sure that there are many management consultants who have made a fortune out of workforce planning, but it seems that everybody gets it wrong. We can only plan ahead for four or five years. We cannot plan ahead for a large number of years.

The Deputy asked what we should do about our current GP primary care problems where practices are full. It is not in the nature of sole traders to turn down business, but this is what is happening. GPs are saying that they are full and cannot take on any more patients. People such as myself can stay on until we turn 72. That has been an improvement. I believe we have to expand allied health professionals - a terrible name, but that is the name we use - so that, for example, a physiotherapist with a patient presenting with back pain could certify a patient as fit or unfit for work, as is the case in the NHS and in some of the American centres. There are many little changes that could be made. It is the same situation in our clinical or practice-based pharmacies. There are a number of things we can do in that area.

Expanding the role of the practice nurse is important too. To expand on Deputy Kelleher's point, there is no doubt that the systems that work well, where there is good patient satisfaction, a better range of clinical services and more fairness, are the systems that have many extra staff. Practice nurses are key to this. The practice nurses at the moment are nurses who have left the hospital sector and who perhaps have gone part-time or left to have a family and then come into practice. General practice is one of the areas that hugely values people who have been mothers and who have looked after sick children in the night. Patients value them as well because they have street credibility. The practice nurse in my practice spends a lot of time doing phlebotomy, which is taking blood. It is a very expensive way of taking blood. Part of the rigidity of the current contract is that it does not resource us to employ somebody like a technician, a medical attendant or a phlebotomist at a lower rate. That is a very important area of the contract. In my own practice we have taken on a phlebotomist to free up the practice nurse to do more work in the area of chronic disease. Our practice nurses initially came in to work in women's health when that was underutilised and underprovided, and they have upskilled themselves. They now see that they need to specialise in long-term illness.

On the question of electronic referrals, we still have a fax machine in my practice. People are shocked to hear that in this day and age. We could not do without it. That is the level of technical advancement we are working at. We have a lot of IT as well. When I carried out this report I spoke to a man called John Macaskill-Smith, from Hamilton, on the North Island of New Zealand. He told me that they have developed their primary care IT hugely and the hospitals have developed their own IT systems. However, the two IT systems do not talk to each other. The idea of interoperability, where the two systems work together, is now being discussed. The company Mr. Macaskill-Smith was talking to is a group that works in Nutgrove in Rathfarnham. This company is providing interoperability for New Zealand while we are still relying on our fax machines. The expertise is there.