Michael Harty (Clare, Independent) | Oireachtas source

I thank the Minister of State, Deputy Finian McGrath, for taking the debate.

I am sure he is familiar with the difficulties which primary care has suffered for several years. I am also sure he is familiar with the Sláintecare report. The Sláintecare strategy and implementation plan, published in March, is an extremely important document which provides a beacon of hope for developing primary care services. It is a once-in-a-generation reform programme which must be pursued by the Government and its successors because it is a ten-year vision for change in the health service. Sláintecare is predicated on building our health services around primary care and re-orientating our services away from a hospital-centric model. Primary care will deliver not only general practice but primary care delivery of nursing services, physiotherapy, occupational therapy and mental health services.

The main issue regarding primary care and general practice is the recruitment and retention of GPs. We have a new primary care deal – it is not a contract - which returns investment to primary care and general practice which was removed during the financial emergency measures in the public interest, FEMPI, cuts from 2009 to 2013. It was absolutely essential that those cuts were reversed. The deal involves stabilising general practice by returning funding which was taken from general practice. This was funding for running general practice, not income for it. An important aspect of the new deal is stabilisation.

A second aspect of the deal is to provide chronic care delivery through general practice. A basic tenet of Sláintecare is that chronic care management is delivered through general practice in primary care. A third pillar of the new deal is to expand eligibility to patients, initially to those under 12 but also to those who have chronic illnesses.

Unfortunately, we will have to wait another four years before we have a GP contract and this new deal goes through the system between now and 2022. It is essential we have a new chief GP contract because if we are to address the medical manpower requirements of expanding services and eligibility, we need sufficient numbers of GPs to deliver that service. We are short 500 GPs. If we are to expand eligibility and chronic care, we will need more GPs. If one offers citizens services and eligibility without putting in place the capacity in general practice, then we will have similar waiting lists to those in the UK’s NHS where patients can wait up to a week or ten days before they see a GP for a routine appointment. That is unheard of in Irish general practice. However, one can have great difficulty seeing one’s GP on the day one wants because 70% of GPs have closed their lists to new patients as it is the only way they can control their workloads. One has to address the medical manpower issue in general practice. The only way to do that is through a new GP contract. Talks on a new GP contract need to start in parallel with rolling out this deal and it has to involve the Irish College of General Practitioners in developing the framework.

We have an ageing GP workforce. Up to 700 GPs are due to retire in the next five to ten years but only 100 GPs under the age of 40 years hold a GP contract. We need to increase our training places but also to attract GPs back to the country who have emigrated over the past several years. We must give them a career structure which they can value and will give them the sustainability they require within the profession.

Community intervention teams are an extremely important part of primary care. They are not rolled out nationwide. In Clare we are lucky to have an excellent community intervention team manned by dedicated nurses who receive people back out of hospital on early discharge, provide them with transitional care, intravenous antibiotics, look after the various equipment patients may have to use and provide an intensive level of care to allow them to return to their communities as soon as possible. We need to recruit more public health nurses. The public health nurse system is struggling to meet the demands placed on it by the early transfer of patients from hospitals back into the community. These nurses are stretched by the number of patients they have to deal with and services they have to provide. It is extremely important that public health nurses are supported and more are recruited to deliver the primary care services for which we all wish.

We need to reorient the health service away from the hospital-centric model to primary care. That requires integration of primary care and secondary care. I had the pleasure of spending the afternoon with Ms Laura Magahy from the Sláintecare implementation office during which we presented to her an analysis of reforms which have taken place in other jurisdictions, particularly in the Veterans Health Administration in the United States and NHS Scotland which has similar problems to ours trying to provide health services for a geographically dispersed population. We also discussed reforms in the Canterbury area of New Zealand which has also experienced similar problems. The most important aspect of those reform programmes was the integration of primary and secondary care. There was a free and seamless movement of patients from primary care to a timely service within secondary care service. It involved the delivery of investigations and treatments in an ambulatory setting which do not require admission to hospital.

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However, that requires access to diagnostics and expert consultant opinion in a timely manner through medical assessment units, acute medical assessment units and ambulatory services to prevent patients from entering hospital to deliver hospital avoidance measures. That is extremely important. When the Minister develops primary care, it cannot be done in isolation. He must do so in conjunction with integrating care in our secondary services.

We had representatives from Mental Health Reform and from the Mental Health Commission before the health committee this morning. Their problem was the delivery of mental health services in primary care and the lack of staff and team members within community psychiatric services. There is a shortage of community psychiatric consultants, community psychiatric nurses, psychologists and occupational therapists and of the provision of cognitive behaviour therapy to provide mental health services within the community. An important aspect of primary care is that we deliver mental health services within the community.

Because of the gaps that have developed within primary care and the shortage of GPs, private enterprise is entering general practice, buying up general practices and putting GPs into work on a salaried basis within a primary care service, which is not in the best interests of patients. We also have pop-up primary care surgeries, which provide one-off consultations but no continuity of care. What people need in general practice is to meet the right doctor in the right place who can make the right decision and continuity of care is critical to primary care. We need to have a dedicated GP service, a dedicated primary care service, where people have continuity of care which is critical for making the right decisions because many decisions are made by inexperienced doctors which lead to unnecessary referrals and investigations. It is critical we have a coherent integrated primary care service.

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