James Reilly (Dublin North, Fine Gael)

I thank the speakers who contributed. I know this is an important issue for all Deputies in the House and, indeed, for all our citizens. I will address some of the specific issues raised in my response. The Bill provides for the elimination of restrictions on GPs wishing to obtain contracts to treat public patients under the General Medical Services Scheme by opening up access to GMS contracts to all fully qualified and vocationally trained GPs. This new legislation will allow many young, highly qualified and trained GPs, who were previously prevented from obtaining a GMS contract early in their careers, to apply for contracts now. The consequence of this was often that many of these highly trained, skilled, bright and energetic people left our shores, some never to return.

Deputy Kelleher and a number of other Deputies mentioned an ongoing shortage of qualified and trained GPs. In this regard, the Irish College of General Practitioners and the HSE have reached an agreement on an assessment tool for evaluating GPs currently working in the Irish health service, but who do not meet the criteria set down in the GMS contract as currently construed. This practice-based assessment model will facilitate the implementation of appropriate fast-track training for doctors who have extensive experience in Irish general practice, but lack some component of training making them ineligible for specialist registration.

Prior to this, doctors in this position had no option other than to commence a four-year GP training programme, as no other training options were available. This was clearly grossly inefficient and not the best use of their time as these experienced doctors had often previously covered many aspects of the training. The purpose of this scheme is to develop a practice-based assessment model as an alternative route to GP specialist registration and it should considerably shorten the time to completion.

In addition to this and following on from the recommendations of the 2010 joint committee report, "Primary Medical Care in the Community", to which Deputy Ó Caoláin alluded, the number of GP training places was increased from 120 per annum to 157 per annum on 1 July 2010, following collaboration between the Irish College of General Practitioners and the HSE.

It should also be noted that the number of GP contract holders has increased from 2,098 in 2006 to 2,279 in October 2011, an increase of 8.63%. Under the interim entry arrangement in 2009, an additional 124 doctors entered the GMS. The Bill will result in a further increase in the number of GPs available to the registered population. During the coming year I want to explore with the Irish College of General Practitioners how we might expand training further and increase the number of GPs.

Deputy Kelleher also mentioned the importance of health promotion, the work of nurses in the primary care setting and the danger of friction within services owing to cross-over of work. Primary care teams by their nature involve different professionals working in a team environment for the good of the patient. There is evidence that the various professionals have already been working well together in a team environment. I take this opportunity to remind people that one of our guiding principles is that a patient be treated at the lowest level of complexity that is safe, timely, efficient and as near to home as possible. In that regard, much of the work currently being done by general practitioners can be done by practice nurses. This would free up general practitioners for other areas of activity. The recent move to allow 800 well trained pharmacists to deliver flu vaccines to adults is another development in this area which will free up general practitioner time. I expect this co-operation to further improve as the primary care team model becomes an integrated part of our health services.

Health promotion initiatives already form the basis of many innovative projects carried out by primary care teams, including falls prevention programmes, mental health initiatives, smoking cessation projects and so on. The Government is committed to prevention and fully subscribes to the principle that prevention is better than cure.

Regarding the provision of adequate GP out-of-hours cover and the impact this Bill may have on out-of-hours services, GPs are, as part of their contract, obliged to have in place suitable arrangements to ensure they, or their deputies, can be contacted during out-of-hours periods. In many instances, it is the relevant GP co-operative that provides this cover and there is no reason the introduction of this Bill should have a negative impact on the operation of GP co-operatives. It should in many ways support and enhance a co-operative's ability to deliver as GPs will now be far more fully involved and remunerated for GMS and non-GMS patients.

Some 90% of the population have access to GP out-of-hours services in 14 centres nationally, in all HSE regions and in at least part of every county. In 2009, the service dealt with 931,905 calls and with 924,000 calls in 2010. More than 2,000 GPs provide services in the co-operatives There were 706,995 contacts with the GP out-of-hours services up to the end of September 2011, an increase of 55,641 or 8.5% on the same period last year. Some 58% of contacts to date in 2011 resulted in attendance at a treatment centre and a further 10% resulted in home visits. I trust these figures give some encouragement to Deputy Luke "Ming" Flanagan, who indicated that home visits are a thing of the past.

I would like at this point to express my regret that no Member of the Opposition has seen fit to come to the House for completion of Second Stage of this Bill.

On the issue of GP shortages, mechanisms for encouraging GPs to set up practices in rural and urban disadvantaged areas will be considered in the context of the review of the GMS contract. In general, GPs who have established panels in urban or rural areas are unlikely to want to move to other areas where they would have to rebuild a GMS panel from scratch. In addition, the rural practice allowance is available, subject to certain criteria, to encourage GPs to establish in rural areas. This allowance will remain available to GPs meeting those criteria who get a contract under this Bill. More than 190 GPs are currently in receipt of this allowance.

A number of Deputies, including Deputies Kelleher, Ó Caoláin, Healy, Crowe and others raised concerns about shortages of GPs in certain areas. Tallaght was mentioned in this context. I spoke about the situation in Tallaght in my opening speech. In general, GPs starting up in practice want to work out of well equipped modern premises and so are less likely to start off in a single practice. Setting up a modern practice involves considerable investment. Also given the current downturn, GPs are less likely to take on assistants and partners. This applies to many areas, not only Tallaght. I envisage that this Bill will increase the likelihood that GP numbers will increase in locations like Tallaght which has a significant medical card population. I am pleased to have this opportunity to announce that a new GP out-of-hours co-operative opened in Tallaght Hospital on 1 November. This service will serve the Tallaght and Clondalkin areas. There are 40 GPs in this co-operative.

It is well recognised that we have low GP numbers per population in this country. The expansion of GP training places to 157 per year will go some way to addressing this imbalance. As I stated, we will continue to strive to increase that number. The removal of restrictions on GMS entry may not solve all the problems in relation to GP numbers. Infrastructure remains an issue in disadvantaged areas. If, following the introduction of this legislation, this remains an issue, I will be happy, when a new GMS contract is being developed, to consider the need for incentives to encourage GPs to locate and practice in disadvantaged areas. While the Bill allows for GPs to set up anywhere they choose, there are many additional supports given to GPs which will be used selectively to encourage their presence in rural and urban deprived areas. In other words, we will not allow a situation whereby five GP practices can set up on Grafton Street and be supported by the State. That will not happen.

Members will be aware that the programme for Government provides for the introduction of a new GMS GP contract, with an increased emphasis on the management of chronic conditions, such as diabetes and cardiovascular conditions. It is envisaged that the new contract will also focus on prevention and will include a requirement for GPs to provide care as part of integrated multidisciplinary primary care teams. The preparation of the revised GMS contract will be advanced by officials of my Department and the HSE. There will be a full consultation process with relevant stakeholders. Along with the Minister of State for primary care, Deputy Shortall, I will oversee the work of the officials.

On Deputy Ó Caoláin's question in regard to the study entitled "A Model of Demand for and Supply of General Practitioner and Practice Nurse Services in the Republic of Ireland", commissioned by my Department which commenced last month, the purpose of this study is to inform the programme for the implementation of universal primary care which will progressively extend access to GP care without fees in accordance with the programme for Government commitment. The implementation programme requires the development of a model of demand for the supply of GP and practice nurse care to facilitate workforce planning so that the supply of care by GPs and practice nurses meets patients' need for care. The study will address a number of elements, including an estimation of current utilisation rates of GP and practice nurse services, including a breakdown by geographical area to the degree that is supported by the available data; a projection of the effect on utilisation-demand for GP and practice nurse services of demographic change, including population aging and epidemiological trends; an assessment of any mismatch between demand and supply and a sensitivity analysis assessing the effect on matching demand and supply of adopting alternative demographic and epidemiological assumptions.

The study, which will be completed by the end of the year, will identify gaps in areas and provide a model whereby the HSE can monitor ongoing trends. I will be in a position to consider the findings of the study as soon as possible thereafter. As I have stated on a number of occasions, the policies of this Government will be evidence-based. We seek to have that information available to us so that we can target the areas in need of more GP and practice nurse services.

Deputy Healy raised the issue of medical card eligibility. Under the General Medical Services, GMS, scheme, medical cards are made available to persons and their dependants who would otherwise experience undue hardship in meeting the cost of GP services. The GP visit card was introduced in 2005 as a graduated benefit to ensure people on moderate to low incomes, in particular parents of young children who do not qualify for a medical card, would not be deterred on cost grounds from visiting their GP. Applications for medical cards are considered on the basis of income net of tax and PRSI and allowance is made for reasonable expenses incurred in respect of mortgage-rent, child care and travel to work. Medical expenses are also taken into account. Applicants whose weekly income is derived solely from social welfare or HSE allowances and payments are granted a medical card. Where an applicant's income is over the guideline limits, he-she may still qualify for a medical card if his-her personal circumstances cause undue financial hardship. I recently instructed the PCRS to put together a group of medical people to examine the issue of discretionary medical cards, a role previously that of CEOs of the health boards. Given they are no longer in place this matter needed to be reviewed. The group is currently operational and is reviewing discretionary medical cards and the requirement for same.

As of 1 October 2011, approximately 1.7 million people held medical cards and 128,000 held GP visit cards, giving almost 40% of the population free access to GP services under the GMS scheme. Approximately €2 billion is spent on the provision of medical card services annually. This represents the highest level of coverage for GP services under the GMS scheme at any time since the 1980s.

Approximately €2 billion is spent on the provision of medical card services annually. This represents the highest level of coverage for GP services under the GMS scheme at any time since the 1980s.

A number of Deputies mentioned the issue of capping consultation fees charged by general practitioners to private patients. Such fees are a matter of private contract between the clinicians and the patients. While I have no role in relation to such fees, I would expect clinicians to have regard to the overall economic situation in setting their fees. I have anecdotal knowledge that many GPs have reduced their fees in cases of hardship. The issue of the disparity between the setting of some fees was referred to and some of those fees seem very high, in my view. An explanation for a variation would have something to do with the overheads, for instance, where a GP may have invested in new premises while others operate rent free in health board premises. One would expect and hope that those GPs would charge lower fees as the cost base is lower.

During the course of the debate, several Deputies expressed concern that GPs do not advertise their fees. Up to 2009, the Medical Council's guide to professional conduct and ethics for registered medical professionals, placed advertising restrictions on new GPs, whereby they were only allowed to advertise their arrival in an area by way of newspaper notices. Other methods of advertising, including notification of prices, were not permitted. These restrictions have not been included in the Medical Council's 2009 guide and GPs are now free to advertise their services and prices. While GPs are not obliged to display their fees, the Medical Council's guide to professional conduct and ethics states that the fees charged should be appropriate to the service provided and that patients should be informed of the likely costs before the consultation and treatment commences.

Other issues were raised in the course of the debate by Deputy Richard Boyd Barrett. He maintained that we are considering a free market. This is not a free market approach but rather an initiative to allow young, and sometimes not so young, doctors who are suitably qualified, to set up in practice and to treat both medical card and private patients. Other speakers referred to the proposal for free GP care. This was Fine Gael policy prior to the election and it is Government policy now that there will be free GP care during the life of this Dáil. We will start early next year with the long-term illness card holders receiving free GP care and the scheme will be extended.

I have a particular interest in the role of HIQA and while in opposition I called for HIQA to have a role in inspecting primary care premises. The agency has a major job of work as regards inspections and the inspection of primary care premises will be coming under its remit during the life of this Government.

Others have complimented the GP service on what it delivers. Primary care and general practice has delivered for the people of Ireland. It has been remarked that even though two separate methods exist and there are public patients and private patients, no two-tier system has evolved, unlike in the hospital sector. For this alone, GPs should be commended.

We wish to see more work carried out in general practice and a different approach to care and a greater emphasis on prevention and the care of those with chronic illness. A new GP contract will include all these provisions. This contract will allow for an enhanced cost-effective care for patients with better outcomes for patients and greater job satisfaction for those involved in primary care.

I am confident that this legislation will contribute to the commitment in the programme for Government. It will encourage more young GPs to remain in Ireland and to establish their practices here and it will make it more attractive for GPs to move here from overseas. It will also encourage competition among GPs at a time when many fee-paying patients have less money at their disposal. To quote the Taoiseach before he was elected, this Government does not want to see a situation where a young mother has to decide whether she can afford to bring her sick child to the doctor and risk not paying the ESB bill at the end of the month.

This Bill will provide that medical card and GP-visit card patients will have a wider choice of GPs under the GMS scheme and it will also ensure that private patients of new contract-holders who may subsequently qualify for a medical card or a GP-visit card, will not be forced to endure the trauma of changing from a doctor with whom they have established a relationship. I commend the Bill to the House.

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