Dr. Mark Murphy:

I will take a number of the remaining questions, some of which are difficult. Senator Colm Burke asked about ehealth. It is a very heterogenous, complex and large phenomenon. We are very saddened to see the loss of Richard Corbridge. We need to retain people and build incrementally. It is a loss to our health system that multi-annual capital funding was not put in place in respect of this. Professor Horgan and I would agree that it is not about blaming GPs and community-based doctors or hospital doctors, but errors can happen with handwriting and paper. That is the reality. My practice lives off fax machines, which is not good enough. Professor Fahey has shown examples of prescriptions that are illegible. I am frequently unable to read a prescription of 16 drugs, and would not be able to contact the prescribing doctor in the hospital. I am not blaming that doctor. That is a State error, because we have not invested sufficiently in electronic discharges. Electronic referrals have started, which go to the hospitals, and I now do that. It is very useful for the clerking doctor in the emergency department, but we need a full roll-out of electronic discharges when the patients returns to me. We are ready to go on electronic prescribing but, unfortunately, our electronic health records, which have been there for 15 years, do not talk to the secondary care electronic health records, nor do they talk to the pharmacy electronic health records. We are ready to go now. The question of timescale is one for the Department of Health and the Minister to answer. It also requires funding.

GP training numbers have increased to 202 this year. We have now filled 194 places, which is welcome. On whether we can reverse the exodus with a new GP contract, I am of the view that if GPs can do what they are trained to do and manage chronic illnesses, access diagnostics and have a satisfying work environment, we will absolutely retain them. I am very committed to that.

Responding to Deputy Murphy O'Mahony, to put it in context, GPs manage the majority of mental health problems in the State. This includes patients with severe anxiety, generalised anxiety disorder, panic attacks, severe depression and labels that we do not even use for people - just mental health complex phenomena. In my practice, I probably start patients on anti-depressants each week. They work and there is a strong evidence base to show that they are effective. They are in every guideline for managing mental health problems across the world for moderate and severe depression. The first-line treatments are lifestyle, social treatments and psychological treatments. I am afraid that sometimes those psychological services are not there. In the case of private patients, I had a patient recently who spent €1,200 accessing cognitive behaviour therapy for their son aged 15 years. It is an absolute disgrace.

That patient did not start on anti-depressants, although that would have been a lot cheaper. First-line therapy was started but it is prohibitively expensive. I am afraid that it can take a GMS patient up to six months to access psychological services which, when accessed, are excellent. That is the reality.

Gifts from pharmaceutical companies is a complicated issue. I personally do not see pharmaceutical company representatives but indirectly, a lot of our medical education is partly funded by the pharmaceutical industry. It is not a black and white issue but I personally do not deal with company representatives. Transparency is absolutely required in this area. A recent development in this area is the IPHA's Transfers of Value register, which allows one to go online and see who has voluntarily declared income from pharmaceutical companies. The voluntary aspect of that probably needs to change. We need to know those numbers and I would stand over that.

The medicines management programme is an excellent programme run by the HSE that delivers education to patients and doctors. Doctors always need to improve quality and standards. In terms of antibiotic stewardship, for example, it has developed a suite and platform to enable GPs and patients to understand appropriate prescribing. However, sometimes that involves a transfer of workload and that must be factored in, as a matter of basic respect.

I will deal briefly with Versatis before touching on nurse prescribing and the eighth amendment. We can only prescribe cost effective drugs. If there is an indication, we will prescribe it and for neuropathic pain, the prescribing of Versatis by GPs is both legitimate and understandable. I am not blaming anyone but much of the Versatis prescribing came from the secondary care setting, that is, from pain clinics. As a GP, if I referred a patient to a pain specialist and he or she waited for 18 months to be seen and was then referred back to me, I could not just say that I did not agree with the pain specialist, if the drug had been prescribed already. I welcome the initiative to reduce inappropriate prescribing but as a GP, I am expected to spend 15 minutes on an online platform for each patient. As a matter of respect, the HSE must talk to our representative bodies about that. Let us do it and let us consider other drugs on which money can be saved but we must bear in mind that there is a cost aspect to that.

On nurse prescribing, I work with a nurse who is a prescriber and I believe we should get going on this. This is all part of the GP contract. There has been a feeling within general practice for the past 15 years that they have not believed in the current model of general practice. They are finally coming around to that. It is to the detriment of patient care that funding to allow practice nurses to train in this area and to upskill has not been provided. That must happen. Obviously there are quality and educational issues that need to be factored in but most other health care systems have allowed nurses to expand their portfolio of skills and we should allow that to happen here.

On the eighth amendment, Deputy O'Reilly knows my personal opinion. However, I am speaking here on behalf of the Irish College of General Practitioners. The college made a submission to the Citizen's Assembly and to the Oireachtas Joint Committee on the Eighth Amendment of the Constitution, both of which came up with what they believe are workable recommendations. There is a problem with the phrase "GP led" because in the future, we do not know what model will develop. Specialists and clinicians who have an interest in this area, whether in secondary care or in the community, will provide the service. I know there are many clinicians who will do so and that model needs to be thrashed out and delivered. Early medical abortion is delivered with an abortion pill and 1,500 women here took that pill last year. We are talking here about mifepristone and misoprostol pills. There will be a licensing issue and that needs to be factored into the legislation. That is all I can say on the matter. We are talking about two tablets that will need to be licensed.