Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)

The Bill comes before the Oireachtas in, arguably, the worst possible circumstances. It reflects no credit on the Government or on the Oireachtas as a whole. The sorry fact is that the Bill is before us because our International Monetary Fund, IMF, European Central Bank, ECB, and European Union, EU, economic masters insist on it and the Government has to comply.

Setting aside the merits of the Bill itself for a moment - it does have merits - it is a sad spectacle to see a piece of legislation in the vital area of health care having its genesis in this way. It will only add to the cynicism of many citizens about Irish politics, a cynicism that diminishes all in political life - the principled, progressive and hard working as well as the careerists and incompetents. It will be said that it took the IMF to come in to deliver an overdue reform that Irish politicians could not themselves deliver.

I said the Bill has merits and it clearly does. Access to the General Medical Services, GMS, scheme for GPs is far too restrictive. The Minister knows that better than probably anyone else in the Chamber. Many who wish to treat GMS patients cannot do so because of the exclusivity of the current arrangements. The need for change has been widely recognised, although there is division within the medical profession on this, with some arguing for the status quo, but there can be no doubt in anyone's mind that the status quo is not tenable and it must change. One could ask why it has to change. It is clear that it is not serving patients as well as it should. There are too few GPs overall and too few GPs have access to GMS contracts which allow them to treat medical card patients. The problem is one of the core difficulties in our primary care system and it must be addressed as part of an overall patient-centred reform and rebuilding of primary care on the basis of need, equity and, importantly, efficiency.

The changes brought about by the Bill can form part of this rebuilding process but, as I have already pointed out, that is not the reason they are being advanced now. The IMF, ECB and EU has insisted on the changes not for reasons of health care, but, in their words, to "increase competition". The intent of the changes is to remove "restrictions to trade and competition". This is about supposedly increasing economic activity in the area of primary care by making available the State supports under the GMS contracts to more GPs. It is not about improving health care outcomes. If it improves health care outcomes - that is an open question as it is yet to be seen - it will do so incidentally and not as part of a primary care strategy or an overall health strategy on the part of Government. It may well increase or at least keep up GP numbers. It may keep more young GPs in Ireland because they will now have access to the GMS system, but a much more comprehensive approach is needed. I believe the Minister knows that and I hope that would also be his intent.

There is an acute shortage of general practitioners in this State and that is one of the most serious problems in our health service. We have approximately 52 GPs per 100,000 population; France has 164, Austria 144, and Germany 102 GPs per 100,000 of population. We also have a situation in this State where some areas - especially disadvantaged areas - have far fewer doctors per head of population. For example, Tallaght, is one such area. The former Deputy, Mr. Charlie O'Connor, was just mentioned. Heaven forbid that I would not mention Tallaght, because he surely would. In Tallaght there are only 24 GPs for a population of 71,000. That is hugely below even our low State-wide level of provision.

An ESRI report in 2009 showed that in terms of GP distribution, Cork - Deputy Buttimer should take note - Galway and Waterford are better supplied with an average of more than 65 GPs per 100,000 of population, while Clare, Offaly, Laois, Meath, Kildare and my home county of Monaghan have the worst ratios at less than 45 GPs per 100,000 of population. The ESRI predicted that Dublin, Limerick, Tipperary south and Monaghan, gladly, will fare better from now until 2021. The worst served counties will be Meath, Laois, Cavan in my constituency and Wexford. By 2021, it is projected that Meath will have only 27 GPs per 100,000 of population compared to 63 in Cork. Kildare and Laois will have little more than 30 GPs. There are further wide variations in our cities, as I have already highlighted with regard to Tallaght in Dublin. These are worrying indicators.

The question is whether opening up the GMS scheme, without other measures, addresses the overall shortage of GPs and, crucially, if it addresses the unbalanced distribution of GPs which leaves many communities so poorly served. We do not know the answers to those questions but what we do know is that a market-based approach will not ensure balanced distribution of GPs and an adequate service for all communities. It could well see an even greater concentration of GPs in more prosperous areas where there are, for example, a high number of older GMS patients and a potentially bigger pool of fee-paying private patients.

This all points to the need for a comprehensive planned approach to primary care, an approach that is still sadly lacking. The Minister for Health, Deputy Reilly, was a member of the Oireachtas Joint Committee on Health and Children in the previous Dáil, which produced a comprehensive report entitled, Primary Medical Care in the Community.

That report on primary care was an indictment of the previous Government's record on health care delivery, and a very valid indictment it was. It presided over a totally inadequate primary care infrastructure which it was far too slow to develop and improve. As long ago as 2001 the need for 600 primary care teams across the State was identified in the Government's own health strategy. By the end of 2009, only 112 teams were at an advanced functioning stage. This is a disgraceful record.

The committee report also highlighted the shortage of trained GPs and the inordinate delay in bringing forward essential health legislation, such as that providing for information for patients, and the promised Bill to define people's eligibility for health services, which I have raised on the Order of Business time after time. The report correctly stated that the current primary care accommodation infrastructure is outdated and inadequate for the provision of modern services. The report's comprehensive set of recommendations cover GP training, developing the role of nurses, ensuring skills mix in primary care, expanding pharmacists' role and prioritising community mental health services. The report recognises that the provision of primary care centres is essential. Deputies are of one voice on that matter.

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