Jackie Cahill (Tipperary, Fianna Fail)
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I thank the Ceann Comhairle's office for selecting this Topical Issue. The availability of GPs in rural and urban areas is becoming a huge issue in my county. At this stage, five or six positions are being left vacant because there are no applicants. Unless this situation is addressed fairly rapidly it will become a crisis for our communities. In recent months, an urban practice in my town has advertised a vacancy through the HSE three times, but no applicant has come forward for the position. The situation is grave and we must act now to avoid a crisis. We must attract young graduates to GP practices. Unfortunately at present this is not happening. Young graduates are deciding to emigrate, leaving us with a scarcity of doctors entering the system.

When FEMPI was introduced during the financial crisis doctors were hit more than most as 38% was taken from the fees they charged. Taking into account the salaries paid to nurses and other staff in GP practices, they suffered a 45% cut on what they receive from the HSE. This must be reversed and improvements must be made in the payment structure. With regard to the pensions received by doctors, they qualify for €17,000 under the GMS pension. This is a very small pension and it must be examined. It pales in comparison to what is available to managers in the HSE.

There has been a focus on building primary care centres but the reality is that most GPs in rural areas and small urban towns have their own facilities. Pouring money into primary care centres if we do not have GPs available is like putting the cart before the horse. I appeal to the HSE to examine each area before it builds primary care centres. Doctors with their own facilities should be allowed to use them and the extra resources should be put into trying to attract young doctors into rural areas.

Another anomaly is that doctors in a county such as mine must pay for 24-7 cover. They must contribute quite significantly to services such as Shannondoc.

In large urban areas, however, there is no charge on GPs for 24-7 cover. This is an anomaly that needs to be addressed urgently.

Training places need to be increased because there are not enough for GPs at the moment. When GPs graduate it should be mandatory for them to spend a number of years working in this country. We have a very sought after education system for medical doctors but when they qualify a lot of them head to other shores to practise and the country gets no benefit from the investment that has been put in.

Locums are another huge issue for rural practices. The tax treatment of locums has to be looked because it is virtually impossible for a rural practitioner to get a locum to help him out in his practice. One can expect no man or woman to work 365 days a year so it should be made attractive for locums to work in rural and small urban practice.

Community care teams have to be properly funded as these can take a good bit of pressure off local GPs, whether it is through the physio calling to a person's house or community care teams calling to dress a person's wound.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank the Deputy for raising this issue. At the outset I would like to assure the House that the Government is committed to enhancing primary health care services, including GP services. The development of primary care is central to the Government’s objective to deliver a high quality, integrated and cost-effective health service and to reduce the numbers coming into hospitals. The goal is to deliver better care close to home in communities across the country and move away from a system which is too dependent on hospital care. In a fully developed primary care system, 90% to 95% of people’s day-to-day health and social care needs can be met in the primary care setting. The winter period is one where particular pressures occur in the health service. For this reason the Minister for Health ensured that considerable planning was undertaken by the HSE ahead of the peak period. A sum of €40 million was provided to assist in the management of winter pressures and to manage the expected winter surge in demand for hospital care in an integrated way across primary, acute and social care. As part of the winter initiative, South Tipperary General Hospital has been identified as one of the nine focus sites experiencing the greatest challenges in terms of ED pressures. Consequently, under the initiative additional measures have been put in place to support the hospital in responding to surges in demand for emergency care over the busy winter period. These include actions to improve early discharging; increase access to community intervention teams, CITs; and increase access to diagnostics. The winter initiative has allowed for the provision of three additional home care packages per week at the hospital until the end of February 2017.

The winter initiative also recognises that there are specific challenges in relation to capacity at the hospital. The HSE is working towards providing extra surge capacity through the fit out of additional space on the first floor of the hospital to alleviate pressure on the ED. This extra capacity is expected to be available from early May and could be used to accommodate space for up to 11 beds. I acknowledge, on my behalf and that of the Minister for Health, the tremendous contribution of all the front-line staff to meeting the heavy demand on our health service during the peak winter period, both in our hospitals and in our communities. The management by GPs of seasonal pressures, which include many patients presenting with exacerbations of chronic conditions, is an example of how primary care plays a critical role in our health care system. In fact, our GPs were at work over the Christmas and New Year period dealing with a substantial workload while many other people were able to enjoy a few extra days off.

It is important to recognise the commitment of GPs to ensuring a responsive, accessible and high quality service to patients on a year-round basis. Recent data from the HSE indicate that in 2016 there was an increase of around 5% in emergency department attendances nationally. In addition, early January 2017 saw continued significant pressure on our EDs due to high demand, increased incidence of flu and respiratory illnesses across the country, which have been disproportionately affecting at-risk groups such as the elderly, as well as ongoing bed capacity restraints due to staff shortages.

GP out-of-hours services also experienced large volumes of patients in attendance. I understand that the number of contacts with these services increased by 13% in December compared to the previous month. In fact, there were over one million contacts with GP out-of-hours services in 2016, an 11% increase over 2015. The Government is committed to the continued development of GP capacity and in 2017 the training intake will increase for the second successive year, from 172 to 187 places. Further efforts undertaken in recent years to increase the number of practising GPs include changes to the entry and retirement provisions for GPs under the OMS scheme, as well as the introduction of an enhanced supports package for rural GP practices.

Jackie Cahill (Tipperary, Fianna Fail)
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Despite the Minister's reply, I do not believe the scarcity of GPs is being addressed. We spoke about health services the other night and about giving people the option of being cared for in their own homes. The preferred option of most people in their old age would be to be looked after in the security and comfort of their own home but if we do not have a proper GP service in rural Ireland that cannot happen. I can give examples of seven different locations in my county which are now without a GP. This is a career choice for young graduates coming out of medical school but it is not financially viable for them to go into practice. A doctor who practised for 15 years in a rural town in Tipperary has decided to emigrate to Canada and it is obvious that there is something seriously wrong with the way GPs are funded by the HSE.

The issue has to be addressed as a matter of urgency. A lot of the infrastructure in rural Ireland is under huge pressure but if we lose our GP infrastructure it will be a death knell for people. We just cannot do without it. I appeal to the Minister to examine the pay structure but other things can be done to alleviate some of the pressure on GPs. Paperwork is a huge burden and if a group of practices were given a project manager to look after the paperwork for them it would be a great help to them. It has to be recognised that rural practitioners are different from practitioners in the large urban centres and have to be catered for accordingly.

Catherine Byrne (Dublin South Central, Fine Gael)
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There has been an increase in home care packages. I am a Dublin Deputy but I recognise that the GP service in rural Ireland is in crisis and needs to be supported in more ways. The Deputy referred to emigration but a lot of young people, whether nurses or GPs, want to travel and experience other types of hospital care across the world. It would be unfair to prevent young people from leaving the country once they had finished their training. There was huge difficulty over Christmas, even in Dublin, over GP call-outs but there are commitments by this Government. In respect of new GP contracts, the Minister is very clear that future contractual teams should enjoy the support of a broad community of GPs and be informed by the input of key stakeholders.

To achieve this the Minister has put in place a process that will honour the framework agreement of 2014 with the INMO and include formal consultations between the State and the NAGP. The Minister is pleased that this arrangement has commenced and hopes for constructive and positive engagement. Something is happening, therefore, but, unfortunately, it is probably not happening for many small rural communities. We hope, however, that in the coming months there will be an increase in GP services across the country, particularly locum services. Nonetheless, I will bring the concerns the Deputy has raised to the attention of the Minister and ensure he receives a response from him.