Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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The next issue will be discussed by Deputies Mattie McGrath and Jackie Cahill.

Mattie McGrath (Tipperary, Independent)
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Ar an gcéad dul síos, I thank the Ceann Comhairle and his good deputy, now sitting on this side of the House, for allowing us to raise this important Topical Issue. However, I wish to record that I am disgusted that the Minister for Health is not here. I met him in the corridor behind the Ceann Comhairle's seat only 15 minutes ago, so he is in the House. This is not the first time that this has happened. He is running around on the phone but he will not come in and answer questions.

In front of our eyes, we can see what is happening. General practitioners in rural areas are disappearing.

A report out today states that 666 GPs are currently over 60 years of age and that 244 of these are over 65 years of age. I have been warning the Minister and, indeed, his predecessor, our current Taoiseach, about the impending crisis in rural general practice for a number of years. We are now even closer to the cliff edge, with the viability of general practitioner services in significant areas of the country at stake. It is obvious. Today's report is stark and deeply worrying. It shows that Cavan, Clare, Dublin, Kerry, Offaly, Tipperary, Cork and Wexford stand to lose at least 25% of their GPs in the next seven years. That is a crisis by any definition. Of course, the HSE would not see a crisis if the combine harvester in front of Agriculture House drove over and hit it with one. It cannot, or does not want to, see a crisis.

One of the frustrating aspects of this saga is that the Government could immediately address some of the burn-out issues confronting a significant number of GPs by reviewing the silly implementation of the children under six free GP scheme, which I and the Tipperary GPs opposed. We were the last people standing. Now, we see the rewards of it. Since the implementation of the scheme attendance by these children at some practices has increased by up to 40%. It is crazy. They would not be there at all if the scheme was not in place. This is clearly impacting on GPs. The Minister must examine this.

He should also examine the financial emergency measures in the public interest, FEMPI, legislation, which crippled GPs. Some 35% or 36% of their income was wiped away. It affected not only their earned income but also the equipment they use to run their premises and so forth. They have provided a valuable service in Ireland over the decades. They are the front line but they have an onerous task. Many of them are fleeing the country. I await the Minister of State's response because this is outrageous.

Jackie Cahill (Tipperary, Fianna Fail)
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I thank the Ceann Comhairle for selecting this Topical Issue. It is a significant issue throughout Ireland and is a particular problem in Tipperary over the past 12 to 18 months. We have failed to attract young doctors into practices, even practices that appear on the surface to be very attractive. We must tackle this problem immediately.

Some 27% of doctors in County Tipperary will retire in the next seven years. This problem must be approached on a number of fronts. One of them is finance for primary care. There is not enough investment in primary care. A study was carried out in a practice in Longford recently where proper primary care was being provided for diabetes patients. This reduced complications by 80%. The saving this generated in avoiding expensive secondary care is enormous. Primary care needs more nurses, physiotherapists and occupational therapists. If resources were put into primary care, the savings down the line would be immense.

The quality of life must be addressed to attract young doctors into general practice. We expect doctors, particularly those in single practices, to work extremely long hours. They have alternative options in Canada and New Zealand that are far more attractive. If we are serious about this, we must change their terms and conditions. New contracts and a new pay structure must be put in place. There must be investment incentives for rural doctors to upgrade their premises. Rural practices are not part of a primary care centre so if tax breaks were put in place to incentivise doctors to invest in their practices it would be a great help. Many local practitioners feel frustrated that they do not have the wherewithal to invest in their practices. The FEMPI legislation implemented huge cuts, including a severe cut to the rural practice allowance. That must be restored and increased to approximately €25,000. The travel allowance, or distance code, had a huge effect on primary care in rural areas.

All these issues must be addressed if young doctors are to be willing to take up the challenge of serving in these practices.

Finian McGrath (Dublin Bay North, Independent)
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I thank Deputies Mattie McGrath and Cahill for raising this important issue. I assure Deputy Mattie McGrath that the Minister, Deputy Harris, is hard working.

Mattie McGrath (Tipperary, Independent)
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He is out in the corridor. He is afraid to come here.

Finian McGrath (Dublin Bay North, Independent)
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He is working 24-7 on all sorts of issues across the board. It is an extremely important portfolio.

The Government is committed to the continued development of GP capacity to ensure that patients across the country continue to have access to GP services, especially in remote rural areas and in disadvantaged urban areas, and that general practice is sustainable in all areas into the future. We wish to ensure that existing GP services are retained and that general practice remains an attractive career option for newly qualified GPs. As of 1 July last, 2,491 GPs held General Medical Services, GMS, contracts with the HSE and this is continuing to increase year on year. A further 438 GPs hold other contracts to provide services such as immunisation, the national Heartwatch programme, methadone and cancer screening.

The HSE, based on the demographic profile of current GMS GPs, expects that approximately 157 GPs may retire on age grounds between 2017 and 2021. Efforts undertaken in recent years to increase the number of practising GPs include changes to the entry provisions to the GMS scheme to accommodate more flexible shared GMS GP contracts and to the retirement provisions for GPs under the GMS scheme, allowing GPs to hold GMS contracts until their 72nd birthday, as well as the introduction of enhanced supports for rural GP practices. These steps should help to address the future demand for GPs by enticing GPs who may have ceased practising for family or other reasons back into the workforce, facilitating GPs to work past the standard retirement age and encouraging more GPs to work in rural areas.

Separately, the State is seeking to train more GPs to provide GP services to the population. A Programme for a Partnership Government commits us to increasing the number of GP training places to 259 annually. In 2009 there were 120 places available and in 2017 there are 186. This is an increase of 55% in seven years. The Minister is anxious to achieve further increases in the number of GP training places in future years and officials from the Department of Health are working closely with the HSE and the Irish College of General Practitioners, ICGP, to ensure that all available places are filled to meet the future manpower needs of general practice.

I accept the point that there are many challenges facing those in general practice. That is why the Minister has repeatedly emphasised the need for a new GP services contract which will help modernise our health service and develop a strengthened primary care sector. Health service management has already progressed a number of significant measures through engagement with GP representatives in recent years. These include the introduction of a diabetes cycle of care for adult patients with type 2 diabetes, an enhanced support framework for rural GPs, which is expected to double the number of qualifying GPs to approximately 330, and a revised list of special items of service under the contract to encourage the provision of more services in the primary care setting. These measures, combined with the children under six and the over-70s initiatives, will increase the financial support for general practice.

The next phase of engagement on a new GP contract is under way and the sustainability of general practice in rural areas will be considered in this context. The process will also seek to introduce further measures aimed at making general practice a fulfilling and rewarding career option into the future.

Mattie McGrath (Tipperary, Independent)
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It is typical to read out a reply prepared by the mandarins. The Minister for Health is not listening and rural Ireland, as is normal, will be hardest hit by the retirement level among GPs. The figures are available. I do not know where the Minister of State got his figures for the usual spin. There are two GP associations to be dealt with. The Minister, Deputy Harris, and the HSE must address this as a priority, not least because if people do not have access to local GPs they will end up in accident and emergency departments, and the crisis in emergency departments is growing every day. It is appalling. The GPs are not respected. The contract is 40 years old. The GPs give huge time to providing a wonderful service. I compliment all the GPs in Ireland for the work they do on the front line and in dealing with crises each day, ranging from those in a single practice to those in the many big ones, including the three or four in my home town of Clonmel, in Thurles and elsewhere. The Government is seeking to roll out primary care centres, to be paid for through public private partnerships. They are not a success either. They are failing. I was surprised to hear today that one in Mitchelstown, across my county's border, is struggling. They are not the answer.

It is all spin that looks lovely on paper. The Government must act to support the GPs. It must deal with FEMPI and the other issues and give the GPs a half decent rural practice allowance. Let them do what they are trained to do under the Hippocratic oath, namely, serve and save sick people. They should not be treated as if they were little better than skivvies, which is how they are being treated. Again, the Minister should have been here. He is out running around the corridor. I know he is getting married and is busy, and I wish him well in that regard. Nonetheless, he should have been here for this debate.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Is the Deputy going to the wedding?

Mattie McGrath (Tipperary, Independent)
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I have not been invited yet.

Jackie Cahill (Tipperary, Fianna Fail)
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While I appreciate the Minister of State's response, he did not address the issues. He referred to additional general practice places and so forth. Doctors are deciding their fate with their feet by choosing to emigrate. A doctor who was in practice in Tipperary for ten years emigrated recently, leaving a major void in the town. For two years, a practice with 800 medical card holders in my home town of Thurles failed to attract a single applicant to take it over, although a locum recently agreed to take it over for six months.

It is obvious that the terms and conditions available to general practitioners are not sufficiently attractive to persuade young doctors to take up the challenge of running general practices in both urban and rural areas. The severe cuts imposed under the financial emergency measures in the public interest legislation must be reversed immediately. A new contract must be introduced to make it financially attractive for young doctors to take up the challenge of general practice. Investment in primary care centres will be part of addressing this challenge because it will generate substantial savings in secondary care. A doctor told me recently that it was no longer practical to stitch cuts sustained by young men playing hurling and all these cases are being referred to accident and emergency departments. This adds significantly to the costs of accident and emergency units and worsens overcrowding.

I appeal to the Minister of State to address this problem, which is getting worse by the day as the age profile of doctors increases. A contract must be introduced with terms and conditions that will convince young doctors to remain in Ireland.

Finian McGrath (Dublin Bay North, Independent)
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I reject Deputy Mattie McGrath's comments about the Minister for Health, Deputy Harris. The Minister is exceptionally hard-working and deals with the issues that matter on a 24-7 basis.

Mattie McGrath (Tipperary, Independent)
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He should come into the House and face us.

Finian McGrath (Dublin Bay North, Independent)
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To respond to the Deputy's points on rural Ireland, we listen to the views of people living in rural areas. I do not engage in spin; I pursue sound policies.

Deputy Cahill called on the Government to deal with the issues facing general practitioners. Let us consider the facts regarding general practice. As of 1 July, there were 22 vacancies in the General Medical Services scheme nationally. As there are currently almost 2,500 general practitioners contracted to provide services under the scheme, this constitutes a vacancy rate of less than 1%. All vacancies are currently covered by a locum general practitioner, which means a GP service continues to be provided in all the affected areas.

Mattie McGrath (Tipperary, Independent)
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That is not true.

Finian McGrath (Dublin Bay North, Independent)
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In 2016, the total amount paid to general practitioners under the General Medical Services scheme was approximately €518 million, including more than €85 million in subsidies for the employment of staff, namely, practice nurses, practice managers and secretaries. Some GPs also receive payments from the Health Service Executive under various other measures such as the Heartwatch scheme and the Health (Amendment) Act 1996. The total amount paid out in such fees increased to approximately €44 million in 2016.

I acknowledge the issues raised by the Deputies and accept that vacancies must be filled and that some young medical graduates are moving abroad. However, we are addressing these issues and doing our best to ensure excellent general practice services are provided throughout the country. Priority must be given not only to recruiting more general practitioners in rural areas but also in disadvantaged areas, including areas in my constituency of Dublin Bay North. We will push very hard to achieve this.