Dáil debates

Wednesday, 24 September 2014

Health (Miscellaneous Provisions) Bill 2014: Second Stage (Resumed)

 

10:55 am

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael) | Oireachtas source

I welcome the Minister of State to the House. I also welcome this very important legislation which concerns the regulation and registration of all health care professionals. We are not just talking about doctors and nurses but also opticians, optometrists, radiologists, radiographers and all of those working in the health care sector. Such people must be registered properly and engage in continuing education. This will give comfort to patients and reassure them that they are being looked after in the most professional manner possible.

Some of the remarks made by Deputy Healy-Rae regarding GPs require a response. While I do not want to down play the seriousness of the concerns raised by GPs, it must be said that being a GP is a great privilege. It is a privilege to be able to work with patients and to have their trust. It is an extremely rewarding job. That said, GPs do have genuine concerns. Their job is not getting any easier but that has a lot to do with the fact that peoples' expectations have changed. The Minister of State has a full grasp of the issues, as does the Minister for Health, Deputy Varadkar.

Deputy Healy-Rae referred to the fact that there must be certain minimum standards in general practice. It is ridiculous of the Deputy to suggest that patients in the 21st century should be seen in general practice surgeries that do not meet minimum standards. Those who take pride in their work would like to think they are working in premises which are fit for purpose and meet minimum standards. Years ago when I was a locum I worked in GP surgeries which did not have hot water or functioning toilets and which had consulting rooms which were totally unsuited to seeing sick patients. In recent decades, that situation has changed quite dramatically and the quality of GP premises is generally up to standard now. There is no need to worry about the setting of minimum standards. It must be possible to clean a GP surgery properly. Allowances must be made for the possibility of spilling blood or other potentially dangerous substances. All surgeries should have autoclaves for sterilising equipment. It might sound ridiculous to say this, but all surgeries should have running hot water. It is essential that we would aim to achieve such basic standards.

The draft GP contract that was presented earlier this year is not the contract that will be offered to GPs at the end of the day and it is important to put that on record. There is no gagging clause for GPs. An estimated 350 GPs are expected to voice their concerns outside the Dáil today, which indicates that there is no question of them being gagged. There are general practice forums on the Internet. There are health forums where politicians express the concerns of general practitioners. That is the way it has always been and it will remain so. There is no such thing as a gagging clause on anyone who is practising medicine in this country. That notion needs to be put to rest and that nonsensical talk must stop.

It is important to ensure that we have enough GPs in the country and that we have a contract that is fit for the 21st century. The contract that GPs are currently working under dates from the 1970s. It is an acute illness contract and will not work for the future because the future of general practice, sadly, is about developing chronic illness care and management programmes for patients. We have had an explosion of health issues like diabetes, hypertension, obesity, high cholesterol and so forth. These are all chronic illnesses that must be managed. GPs who were practising in the 1970s when the current contract was introduced can tell stories of patients presenting to them with end-stage cancers - fungating masses of breast cancer or bowel cancer that had gone way beyond any chance of effective treatment. Those days are gone because we screen for so many illnesses now. We have very effective screening programmes for breast, bowel and other cancers as well as much more effective treatments for same. The medicine that was practised 40 years ago is not the medicine of today. I qualified 20 years ago and some of the treatments that were lauded at that time would be laughed at now. General practice has changed dramatically in recent decades.

The biggest investment needed in general practice is in ICT. Technology has changed dramatically in the past 15 years. When I started in general practice, many GP practices had no secretaries or practice nurses and no IT infrastructure whatsoever. Nowadays, all patients notes are on computer and all blood test and X-ray results are transmitted via broadband. GPs are not yet able to refer patients to hospital via computer because the hospitals have not developed their IT structures to allow doctors to refer by e-mail, but such developments will come about. I have not vaccinated a child in three years because my practice nurse does all of the childhood vaccinations, as well as the influenza vaccinations for my elderly and chronically ill patients. In contrast, 15 years ago there were very few practice nurses in general practice here. General practice is evolving at a tremendous rate and we must have a contract that reflects that reality. Change always frightens people and I have no doubt that the draft contract upset many people. Some of the issues raised in the contract were controversial but much of what is in the draft must be included in any new contract. We must have chronic illness care programmes in place. Structures must be put in place to allow us to deal with chronic illnesses for the next 20 to 30 years and the new GP contract must reflect that.

The increase in obesity levels here is shocking. A doctor examining children 20 years ago would have been able to see their ribs but that is not the case today. Obesity is reaching epidemic proportions.

I am in favour of what Dr. O'Shea, the endocrinologist who specialises in obesity problems in this city, is saying, that we should ban soft drinks from secondary schools. Soft drinks are a curse on this nation. We should get it across to the public that one should not have soft drinks in the fridge at home and one should not have easy access to them. Soft drinks are a significant part of the problem of childhood obesity. It is amazing the sugar load across a number of products that children and teenagers include in their diet on a daily basis and it has contributed to a significant obesity issue. For many of these children, this leads to issues around their self-image and self-esteem and that then reduces their participation in sports activities which only compounds the problem. When we used to diagnose patients with non-insulin dependent diabetes, we would hardly ever check anybody under the age of 60 to see if they might be diabetic. Now I am diagnosing patients in their 40s and it is becoming quite common to diagnose those in their 50s with non-insulin dependent diabetes. That quite significant change has occurred over a generation and it is one that will get worse unless we take this issue seriously and do something about it. That is built around the issues of preventative health measures and health promotion. These messages do not seem to be getting through to the general public and it is a serious issue. We need to be a little more proactive and we should reconsider the issue of not having soft drinks available. In regard to the health of the nation, soft drinks are more of a threat to this country and others, such as America, than al-Qaeda could ever be. There is a need for us to do something about it fairly urgently.

Deputy Healy Rae raised the issue of agency staff and retaining doctors. We are in an incredible position in this country where we train 600 doctors a year in six or seven medical schools, if we include the postgraduate schools, over half of whom we export in three years. There must be an issue here. Those graduates are going, for instance, to the HSE, to take up senior positions and consultancy jobs. There must be more of an issue than merely what Government can do in this regard. There is a serious issue around the postgraduate training in this country and that is something that the postgraduate colleges must face up to and do something about. We might as well close two or three medical schools and invest the €20 million or €30 million we would save as a result in postgraduate training or at least in making these positions more attractive for our own graduates to stay in this country. Many of the graduates who leave to go to the United Kingdom enter full training graduate schemes where they start as senior house officers, go right through all of the ranks of medicine and qualify as consultants. We need to put that sort of system in place in this country, where one will finish an internship here, start as an SHO, and go through SHO, registrar, senior registrar and specialist registrar and qualify as a consultant, and that one will know exactly where one will work and for how long in this health care system. Such a scheme does not exist at present and that is why other countries which have better postgraduate training schemes in operation, such as the United Kingdom, Australia and America, are attracting the best and brightest of our graduates. Unfortunately, when someone goes to work in another health care system for more than four or five years, he or she finds it difficult to come back. I have seen that with some of my classmates over the years where they have come back to consultancy posts in this country, stayed for between six or 18 months, and then gone back to the system that they are used to and comfortable with. We are then left behaving like a parasite towards Third World countries in looking for their best and brightest. It is an unsustainable way of operating the health care system. It is not only the Government that is responsible. There have been many reports, dating back to the Fottrell report in 2006, on this. There were reports on both undergraduate and postgraduate training for medicine. The issue here is that the postgraduate training schools must face up to their responsibilities too. The hospitals and universities are closely linked and they need to put together schemes to train our own graduates and keep them interested in working in this country.

The issue of agency staff also relates to training. I hope that there will be less reliance on agency consultants. The agency consultants issue has nothing to do with the moratorium. The moratorium on employing nurses definitely is having an impact on the hospitals and that needs to be looked at by the Ministers, Deputies Howlin and Varadkar. In many cases, when it comes to hospital consultants it is merely that the hospitals are not attractive for young doctors to work in. Doctors who trained in large hospital training centres where they experience much peer review and many colleagues with whom they can liaise, are not interested in going to work in small departments in medium-sized hospitals where they feel isolated and left to their own devices. The new hospital groups the Government is establishing will improve graduate perception of these consultancy jobs, and we need to speed up the groups' establishment. If such doctors are involved in such groups, if they work with other doctors and if they are able to do specialist operations in the bigger hospitals and then do the more minor procedures in the medium-sized hospitals, that will make a significant impact in hospital medicine in the future.

I welcome the Bill. It is important that every person working in health is registered and regulated and every person who has a role to play in patient management participates in continuous medical education of his or her profession. It sounds astounding but if one qualified prior to 2006, for instance if one qualified as a GP in 1966, one would not have to show any competence that one had kept one's medical education up to date in such a case from 1966 to 2006. That has now changed. We must participate in continuous medical education and that is the right way forward because, as I stated, the treatment options that we would have been using when I qualified in 1993 would be to some degree out of date now. It is important that we keep up to date in what we are doing.

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