Tom Barry (Cork East, Fine Gael)

I welcome the opportunity to contribute to this discussion on the Health (Provision of General Practitioner Services) Bill 2011. The Bill addresses issues highlighted by the EU-IMF programme and aims for legislative changes to remove restrictions to trade and competition in sheltered sectors. It provides for the elimination of restrictions on general practitioners wishing to obtain contracts to treat public patients under the general medical services scheme by opening access to GMS contracts to all fully qualified and vocationally trained GPs.

At present, GPs can only obtain GMS contracts under limited circumstances where a vacancy arises due to retirement, a new panel is created due to additional needs being identified in an area or where a GMS doctor obtains approval from the HSE to take on an assistant with a view to a partnership in his or her practice. The Bill will allow patients a greater input in terms of nominating a doctor of their choice. No longer will it be the case that a private patient has to move to a different GP because he or she is entitled to join the GMS. The commercial viability of GP practices in an area will no longer be a factor in awarding GMS contracts and contract holders will be free to establish their practices in locations of their choice. The legislation will encourage young GPs to remain in this country and encourage competition in the sector.

The current GMS scheme provides free GP services to public patients throughout the State and covers 39% of the population, up from 34% at the start of 2010. The previous GMS contract was to all intents and purposes a contract for life but GPs were free to terminate their contracts at any stage after giving a minimum notice of three months. It was a one-sided contract. We often hear of discrimination between private and public health care. However, certain GPs could only treat private patients and not public patients, which might have led to the assumption that the GPs on the GMS scheme were giving a better service. Affordability is also relevant because GPs with GMS contracts were charging the same fees as those who only had a private contract when business principles suggest that a larger patient base and a guaranteed source of income implies those practices would have been better value for money. This is not the case, however, and GP figures remain too high and too variable.

This legislation, which has been earmarked as part of the EU-IMF programme of financial support for Ireland, should have been introduced years ago. However, the medical profession is now going to be regulated prescriptively because it failed to address the issues arising through self-regulation. Having a GMS contract proved profitable to many GP clinics, with 58 receiving more than €500,000 in 2009. The long disputed scoring system used to award entry into the GMS scheme is also being reformed. This system proved frustrating to new entrants because it effectively gave existing GPs an advantage over them.

The HSE has been progressive in its approach to GMS contracts but this legislation is required to help it in its task. Only a few months ago the HSE facilitated a six month trial period for a GP service in Doneraile, County Cork, provided that the new GP could demonstrate adequate demand for his services from GMS patients in the area. I am grateful to the HSE for its assistance and, with the support of the local community, the practice is proving successful.

The Competition Authority has pointed out that between 1982 and 2005 there was a large decrease in the number of GPs with lists of fewer than 1,000 patients and a simultaneous increase in the percentage of those with more than 2,000 patients. In effect, larger GP practices were mopping up the smaller practices as they became available. We do not want to emulate the situation that obtains in London, where a few GPs employ large numbers of salaried assistants who have no prospect of securing permanent employment.

One aspect of the GMS service not addressed in the Bill is that the visitation rate among individuals who receive GP services free of charge is significantly higher than among those who pay for their visits. In 2007 medical card patients visited their GPs an average of 5.2 times compared with 2.4 visits among those with private health insurance and only 1.9 visits for those without medical cover. This is a significant disparity. Whatever the underlying reasons for this disparity, we need to be aware that the considerable number of people who were in the middle income bracket until the financial meltdown and can no longer afford private medical insurance may be compromising their own health or that of their dependents because of financial distress. This is a worrying trend.

The new legislation will allow the HSE to take a more proactive role in ensuring adequate GP coverage. This is important because patient care has to be central to any changes made. The Irish Medical Organisation has stated that it remains to be seen how well services to patients will be protected. However, it seems that it was late in updating its interview marking scheme for obtaining GMS contracts and slow in trying to regulate this sector. It has also indicated that the shortage of GPs in Ireland is due to worsen in the short term. Approximately 2,800 GPs are registered to practise in Ireland, which represents a ratio of 0.6 GPs per 1,000 of population. The IMO has also stated that practices will have to ensure they have sufficient resources to provide fully staffed and equipped services from modern premises. I welcome this statement from the IMO and hope it was issued out of concern for patients rather than as a cynical obstacle in the way of new GPs. Capital costs are incurred in the establishment of any new business and a GP practice is essentially a business. In light of the IMO's concerns about sufficient resources for new practices being sufficiently resourced, the funds should come from the GP sector. It could be based on the modulation arrangements in the agriculture sector, whereby every GMS recipient pays a percentage of income, such as 6%, into a common fund. The amount paid could be based on earnings, with those earning less contributing a smaller proportion than, for example, the 58 GPs who earn over €500,000 per annum. Those who earn less than €5,000 should not have to make a modulation contribution. This would create a fund of €26 million for primary care centres.

Targeting GMS funding towards GP practices in primary care centres should be further explored. Primary care centres such as the one in Mallow are proving successful in treating patients with chronic illnesses, such as diabetes, at 20% of the cost of the same treatment in hospitals. Any industry which does not put aside funds for new entrants or exceptional circumstances will inevitably run into trouble. It is astonishing that it took the IMF to highlight this issue. The IMO has stated that competition must be implemented with care, and that markets can produce instability, variations in performance and inequalities which might be at odds with the underlying principles of the health service. However, this legislation will help us deal with any of the organisation's concerns.

In summary, change is never easy and there will be cost implications to be borne by many of the excellent general practitioner practices that are being run in a professional and dedicated manner. In the longer term, however, it is better to have a situation where all general practitioners are treated as equals and no obstacles are put in the way of suitably qualified young general practitioners setting up a business where they choose to live and work. It makes no sense to force young general practitioners to emigrate after many years of expensive education which is paid for by the taxpayer, especially when the number of general practitioners is at such a low level. This Bill will benefit the Government, the general medical services that administer the general practitioner scheme and, most importantly, the patient.

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