Liam Twomey (Wexford, Fine Gael)

I have the honour of being one of those who can get up in the middle of the night to see patients. Unlike the vet, tiredness and fatigue are not options if one is a general practitioner. If one makes a mess of it as a GP, one cannot write it off as another cow or a calf. It is far more serious than this and I am sure Deputy Luke 'Ming' Flanagan knows exactly what I am talking about.

This legislation is very good, although long overdue. In introducing such legislation, however, we must ensure there is no potential downside to it. Some excellent changes have happened in general practice in the last decade, including the provision of primary care centres and the grouping of general practitioners. We are reaching critical mass in order that we can have allied health care professionals such as secretaries, practice nurses, chiropodists and physiotherapists together in primary care centres, as well as groups of doctors working together. This has been a positive improvement in general practice.

The role of information technology and computerisation in transferring information from hospitals to primary care centres has also radically changed in the past ten years. Some 14 years ago, when I was working in hospitals, there was very little information technology in use. Outpatient departments were run using a paper-based system and, to some degree, it is very much the same today. When I started in general practice around 13 years ago, there were very few practice secretaries or nurses. In addition, there was poor penetration of information technology in general practice surgeries. Many things were very different, but the position has changed radically. Most medical practices now have a practice nurse and all have secretarial support. We have cost-effective primary care services that are working well for patients.

Patients' private fees are an issue on which we must focus. There have been dramatic cuts in the payments made in the medical card system to primary care services, which is having an impact. There has been a reduction in the numbers of practice nurses and secretaries coming into the system, but this is not impacting as much as we thought it might.

In opening up the system we must also introduce minimum levels of patient care. We cannot return to a time when there were GP surgeries in garages stuck at the sides of houses. That would mean one could not have a practice nurse, chiropodist or physiotherapist, introduced as a result of the massive improvements made in the past decade and we want to maintain that progress.

In addition, HIQA should provide for a basic level of services in GP surgeries, with proper standards of patient care in primary care centres. There is nothing in the planning Acts to stop someone from converting a small shop to a small GP practice, bringing us back to where we were 15 years ago. That is not the best approach to adopt for patients.

The Minister of State with responsibility for primary care, Deputy Shortall, is present in the Chamber. I have spoken to the Minister, Deputy Reilly, who is driving the agenda forward to provide care in primary care facilities, rather than hospitals. We are talking about chronic care management services, looking after patients with high blood pressure, diabetes, arthritis, COPD and a range of other problems. Historically, general practice physicians treated acute illnesses such as chest infections and patients with a high temperature but the patient cohort changes dramatically as the population ages. We are now dealing with chronic problems such as diabetes, from which a patient may suffer for 20 or 30 years. If diabetes is not dealt with properly, it can lead to significant complications, including amputations, heart or kidney disease. The same goes for COPD, chronic obstructive lung disease, which can continue for a long period. If it is not managed properly in the early years, it leaves a patient with a poor quality of life. Such chronic care management is best provided in large private care centres with more than two or three doctors working in them, supported by practice nurses and HSE staff.

If we were to revert to the old system under which a GP could set up anywhere he or she liked, those worst affected by it would be in the disadvantaged Dublin areas. There are already gaps in primary health care for those living in disadvantaged urban centres. However, people living in rural areas also suffer. There are two practices in County Wexford that cannot get a GP to work in them. One has had a locum doctor for at least three years, while the other has failed in two attempts to have a doctor appointed to it. We must speed up the process of having doctors qualified to work as general practitioners. I know of cases involving doctors from European countries who have completed their medical training here or in another recognised state, but because the training scheme is not recognised - there are only 150 or so such doctors - they are not eligible to apply for membership of the Irish College of General Practitioners and cannot, therefore, obtain a GMS number. We must not just ensure we have the right types of doctors but also ensure we open up the system properly. The Bill will only see an increase in the number of GPs in wealthy urban areas. There is no problem in getting a young doctor to work in a practice on the southside of Dublin, but it is much harder to get someone to work in Ballyfermot and almost impossible to get them to work in rural areas. At the same time, doctors are able to come here from various parts of Europe who are equally well qualified but whose training is not recognised. We must change what the Irish College of General Practitioners does, as well as the way the Irish Medical Council recognises such doctors. They are suitably qualified because they can work for another GP but not for themselves. There are massive problems in this respect which we must examine in their totality.

It is important to examine the role of practice nurses and what they can do in primary care facilities. They have assumed responsibility for a major portion of the work which they are doing fantastically well. In the practice with which I am associated the practice nurse does antenatal work and provides vaccination, phlebotomy and chronic care management services.

The Minister of State, Deputy Shortall, will be dealing with the actual contract. Every progressive general practice has a care plan for chronic care management but there is no payment for this. If one is doing the right thing for one's patients at present, one is at a disadvantage by comparison with those who are not. The Department and HSE have no idea who is doing the right thing and who is doing the wrong thing because there are no inspections or basic standards. These should have been covered in the legislation. There is an opportunity to ensure we are doing our absolute best.

We know general practice provides a very cost-effective service and that is why we want to move services from hospitals to primary care. We also need to up-skill the general practitioners. While we realise circumstances will change regarding how hospitals provide accident and emergency services and what occurs regarding such services in many parts of the country, the debate thus far has been very much focused on upgrading ambulance services, taking on paramedics, etc. Many general practitioners are trained to deal with trauma at the roadside but there are many who are not trained to deal with trauma or serious illnesses in emergencies. The latter, owing to their living in proximity to an accident and emergency unit in a major hospital, have been de-skilled to some degree over the years.

If there are changes to be made, we need to consider the current cohort of general practitioners and not just engage in competence assurance, which is occurring at present. We must up-skill the general practitioners. While the Mid-Western Regional Hospital Ennis, for example, has not lost its accident and emergency department, it does not have the same number of non-consultant hospital doctors employed as it once had. General practitioners work in the accident and emergency department but not every general practitioner in County Clare can do so because one may not be suitably qualified to do that type of work. There is a need to up-skill general practitioners in order that they can carry out these functions. They are well able to do so.

We should seriously have a proper debate on this and not just focus on a few narrow subjects. There are great opportunities to move towards primary care of a good standard and of high quality. I refer not only to acute care but to chronic care and various other developments in the sector.

Over the past decade, general practice has evolved from general practitioners working single-handedly in their houses to their working in large primary care centres that are fully IT compatible. Some centres have 20 doctors and practice nurses and practice secretaries. A range of services is now being provided and this represents a dramatic change. If the changes were as dramatic in the hospital services as they have been in general practice, we would probably not be talking about hospitals as much as we are at present. If hospital consultants and managers drove their institutions such that they could change as quickly as general practices, in order to give patients what they want, it would be of benefit.

The Deputy is correct that house calls are not as common as they used to be. The question of patients having to travel long distances at night is one of providing an out-of-hours service that encourages young doctors to work in rural areas and small urban areas. Without services such as Caredoc, SouthDoc, Shannondoc, Mid-Doc and North East Doc, we could have a bigger problem in primary care. Who drove these initiatives? It was the HSE, working with the general practitioners and the patients. Irrespective of what Deputies may feel, patient satisfaction rates with the out-of-hours co-operatives are up to 95%. The services are all quality assured and all the calls are tracked. One can trace when a patient rang, when he was rung back and when he was seen. The system is quality assured to an extent that did not obtain heretofore. These are massive improvements and we need to keep driving such improvements. All the stakeholders, including patients, doctors and the HSE, are seeking them.

The process needs to be co-ordinated better and that is why I am glad we have a Minister of State in the Department of Health with responsibility for primary care. Primary care was always a poor relation. When we talk about it, we should not feel it is just about general practitioners and practice nurses within their practices. It is also about the public health nurse and the community psychiatric liaison teams within primary care. It is amazing how they have transformed care for patients with psychiatric illnesses. I want to continue to see progress on having a fantastic service for patients.

I support what is proposed in the legislation but I see the disadvantages. I am glad a section states a doctor can only have 2,000 patients on his list because, if one does not limit the number of patients, corporations could run the primary care system. In Australia, this was regarded as the means of solving some of the country's manpower problems but it ended up causing problems. The Australians worked on the same basis promoted in the Bill with a view to promoting competition and improving services, but the result was the opposite of what was expected. Services cost more and patient satisfaction is lower.

When we are trying to make progress, we must constantly re-evaluate our approach to ensure we do what is right for patients. We do not want to realise in ten years that we made a mess of the service just because the IMF sought change. There are other aspects to be considered. These include ensuring we have the right types of doctors. As it stands, before we open up the market, we have a problem getting doctors to where they are needed. What this legislation will do immediately is get doctors to where they are not needed. Many doctors would end up in the leafy suburbs of south Dublin but there would be no improvement necessarily in terms of filling the posts in Wexford, other rural areas or deprived urban areas. We must ensure there is a good flow of doctors to take up these positions as quickly as possible. I may speak again on this at a later date.

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