James Reilly (Dublin North, Fine Gael)

I thank all those Members who have contributed to this debate and thank them for their support. It is not too often we get that level of support for a Bill.

There is no question but that this is an important Bill and I will try to respond to the issues in the order in which they were raised. Senator MacSharry opened the debate and I welcome his support. He remarked that there is no incentive in the Bill to encourage GPs to move into poorer areas. He is correct, but that is not what the Bill is about. The Bill is about ensuring we get the highest number possible of fully qualified GPs available to all of the population. A private patient has a choice of doctor. GMS patients had a choice in theory, but if the doctor chosen was not on the medical card list, the patient would have to pay, which does not represent much of a choice. This Bill corrects this.

I mentioned in my speech that we are focused on ensuring that we address and support general practice in black spots to which it is difficult to attract GPs, such as urban deprived areas and remote rural areas. The Department reserves that right with regard to the supports it will provide. In other words, just because a doctor is given a GMS number, this does not mean he or she will get the full range of other supports that might be available. I do not wish to see a situation where, for example, we are supporting five different practices in Grafton Street. However, if the doctors want to set up there, that is fine. That is what competition is about. We have a social duty to provide primary care facilities, including general practice, to parts of the population that would not be commercially viable from the business point of view and we must honour that duty.

Senator Clune raised the issue of two-hour lunches, golf courses and half days off. I do not hold any candle for general practitioners, but I would not like people to leave this House under the impression that is the norm. In the main, general practitioners work very hard and provide a very good service. There will always be individuals who cause questions to be raised, but the tradition of golfing on a Wednesday was a reflection of the fact that the person was working on Saturday and often had to work over night. I do not agree with having doctors on call 24 hours or with working 36 hours. We do not let truck drivers work those hours and I would not like one of my loved ones to be looked after or for a life or death decision to be made by a doctor who was exhausted, who had been working all night and day and who was expected to work the following day. We are trying to get away from that, which is where group practices come in. We want to encourage group practices so that people can work different shifts.

The issue of pricing is a key part of this Bill. We have seen two new doctors start up in Killarney and they are considerably more competitive than those who are there already. We will see more of this happening. The Department has no role in the setting of private fees, nor have I as Minister. Private fees will become part of history in a few years when we roll out free primary care and GP care throughout the country for all citizens. I take on board the point made by Senator MacSharry on the IMO. I have always maintained that it is easier to deal with just one leader. The Americans ask who they should go to when they want to talk to Europe. I look at the situation in Iraq and see that it is far easier to deal with one leader than with 25 different warlords. The IMO still has a key role and it can still discuss many aspects of care and work. However, the Department will retain the right to set the fee and it is in that regard the Competition Authority is concerned.

Senator MacSharry mentioned the issue of coronary stenting in the north west. He is correct. There is an area in the north west where we cannot deliver a similar service to that we deliver throughout the rest of the country. This is an issue I have discussed with the Northern Ireland Health Minister, Mr. Poots, with regard to cross-Border co-operation.

We have had some very good discussions and we are making very good progress, and we have discussed this issue. They were thinking of extending facilities in a hospital and there is not a big need for it. I have spoken about Letterkenny, Altnagelvin and that area, and how we can deliver for both our communities. We are getting on very well in that regard and I look forward to more developments in that area. Not all heart attacks require thrombolysis or stenting but all ST segment elevation heart attacks would need such a procedure, which is a concern.

I worked in Sligo and the north west many moons ago and I was struck by the strength of primary care. As a result of the geographical spread of people, that health board area and subsequently the HSE were very good at supporting primary care general practice. There were many initiatives up there that I never saw in Dublin. That is not to say we do not need to improve, and we will do so.

Senator Burke spoke about the electronic medical record, and his comments are correct. There is much work being done on that currently, with several different options being examined. The one I prefer is held by the patient, and it can be updated on a GP's terminal at any time, as the GP would hold all the information in any event. There could be licensing with regard to tiers of access as, for example, a patient may not want a physiotherapist to know all the detail's of his or her medical care. It may be appropriate in some instances but not in others, but I will not get into examples.

The quality of care is sacrosanct and I will not undermine that concept. The Irish College of General Practitioners and the Irish Medical Organisation, to some extent, have been very good at achieving what we now have in well-qualified general practitioners. I do not want to do anything to undermine that quality, and I will not do so. That is why I made it very clear in the Bill that the application is for suitably-qualified GPs. This is not open to people who did five years of medicine in a hospital and who then decided they wanted to be a general practitioner. People will require relevant qualifications and training.

Value for money was also mentioned by Senator Burke. Some 120,000 people attend general practitioners every day in this country, with 3,500 per day attending emergency departments. One can imagine what would happen if there was a shift of 1%, as that would lead to a 25% increase in accident and emergency activity; if there was a 5% shift, everything would collapse. The person informing the Senator would be in the minority, and anybody going into general practice should be looking to expand their range of abilities in terms of suturing and working weekends. I do not know of any training course that allows anybody believe they will not have to work weekends or that they should not be able to suture a patient. It is a particular concern for me and I have asked for an audit of out-of-hours services for general practice to see how many people have been referred to hospital who should have been treated by a GP. I get a sense sometimes that doctors on call at night - I should not identify locums in particular - may be less inclined to do that suturing work and it is easier to send a patient to hospital. That is unacceptable. It is an ordinary part of a general practitioners work.

It has been mentioned by others that when a large hospital develops, as it did in Tallaght, there can be gradual deskilling of general practitioners. As the accident and emergency department is so near, people can be inclined to go in that direction and we must ensure we have the correct incentives. I take the point about group practice, which is extremely important not just because of economies of scale and the broader range of services but also because of peer group support and monitoring. There is a bit more safety for patients in that respect.

I called for the following in opposition before I became a Minister and I will see that it happens. HIQA should become involved in inspecting general practices and set standards in them with regard to premises and equipment. The process that is happening in our hospitals must spread across this spectrum. HIQA has a large job of work and we must make priorities with our limited resources but there is a clear plan set out for that.

Senator Crown and others, including Senator Healy Eames, spoke about natural justice and demographics, and I agree with those comments. Some 50% of graduates in general from medical schools go into general practice so we can ask where they are gone, in the same way we ask where the 50% of non-consultant doctors are gone. There is a lack of a career path both in general practice and in hospitals. I have already indicated we would address that and I am examining a report relating to the creation of a consultant grade 1 or specialist grade when a person finishes specialist registrar training. One from four specialist registrars becomes a consultant; all four are fit to be a consultant but we do not have enough jobs. Why not create a clear career path where all four move to a specialist grade and move to become consultants in four or five years? This is not meant to be a graveyard for highly qualified people, as has happened in other jurisdictions, but rather a natural progression.

I will make two important points. If people talk about indenture - holding on to medical students when they become doctors, as the taxpayer has paid for them to become doctors - it would cost approximately €150,000 to train a doctor to just beyond intern level. It would cost nearly €1 million to get them to the position of specialist registrar, and that is when we are saying goodbye to them. That does not make sense. I am sure Senator Crown would not disagree with me in saying that this is the time when many doctors are at their most productive and involved in research. We are sending them away and offering them no opportunity to stay. We could have a win-win scenario with this proposal, and these positions would be clinically autonomous, meaning such specialists would only have to report to a clinical director.

Senator Crown also mentioned primary care and a cost-effective health service, and strong primary care is at the core of the fairest of these systems. America spends more than 16% of its gross national product on health but it has the most inequitable outcomes; if a person is well off, he or she will do well, but if a person is less well off, the outlook is pretty poor. Many people could go bankrupt as a result, and we do not want to see that here. Universal health insurance will address this issue.

All GPs have worked in hospitals so they understand the hospital system to a greater or lesser extent. Many consultants have not worked in general practice and would not understand it at all, which should also be addressed. There should be understanding. Bringing GPs into hospitals to work in areas where they have an interest is an excellent idea and, equally, bringing consultants to the community to deliver care is an even better idea. Why should 30 people have to leave Balbriggan or Oranmore when one person could travel the other way?

There was a comment on the two-tier system. Mr. Dale Tussing, an American economist, considered this when the capitation system was introduced and his fear was that with a two-tier system of payment there might be a two-tier system of care, like there are in hospitals. He remarked in the late 1990s that it had not happened, much to his pleasure and surprise. There are lessons in this respect as the two-tier system might come about in one area but not another. We are looking to address the issue through universal health insurance, where everybody will be a private patient and treated the same. People will not have to worry about whether they can afford care, as that will not be a determinant.

Senator Kelly spoke about private fees for letters and social welfare certs, although such certs should not give rise to fees. The medical card and the primary care reimbursement service is a significant area of contention. I know that when I stood here last I indicated that I had been informed that the process was improving. I accept that did not become the case. Last week I visited the service and met Mr. Burke. I am aware that he apologised on radio for the way things have gone and he has taken a different view. As a result of a request from me he has slowed down the review process to deal with the realities he is facing with regard to the volume of numbers he must deal with.

There is no question about the card of anybody on social welfare. People will keep their card until the review is complete, as opposed to losing a card until the review is complete. In fairness to Mr. Burke, we must all acknowledge that 21,000 people had not responded to contact from the service by the end of January this year. Some 4,000 of those people had not had any activity on their medical card in two years. The service has already tried to contact these people twice and a third letter will be sent. We will have hard individual cases, and there may be people who do not go near a GP because they are so well despite having a medical card. They are few and far between.

How will he behave, and how will the Members of this House and the other House behave, if he is challenged at a meeting of the Committee of Public Accounts by Deputies asking him to explain why doctors received payments in respect of 4,000 people who did not use their cards for two years and did not respond to the letters that were sent to them? He might be expected to explain what sort of probity is involved in that.

There are two sides to this story. It is not simple. We want to ensure those who need medical cards, have medical cards and are entitled to medical cards keep them and are not discommoded. We have put in place several new initiatives to ensure they are not discommoded. There is a probity issue here. We cannot pay doctors for people who are not in the country anymore. That is half the point.

I would like to move on to speak about community employment schemes and the guidelines for the medical card. As I have said, we are moving in a determined and ordered fashion towards full general practitioner cover for all. Cancer patients are not on the long-term illness scheme. Leukaemia patients are on it. I have spoken about doctors who work inordinately long hours. It is not something I want to see or stand over. We know that mistakes will happen.

Senator Barrett mentioned what the troika had to say about fees. This is a difficult area. There are many apples and oranges in this scenario. The supports that are given to doctors in Belgium and France are very different from those that are given here. As the Senator knows, all of this will become historic when free general practitioner care is introduced over the next three years. I have mentioned that I am concerned about locums and the deskilling of general practitioners.

Senator Barrett also referred to the important Milliman report on the VHI. Milliman has been engaged by the VHI to further address its cost base. I have said in this House and the other House that I am not happy about the way the insurance companies are dealing with the cost of the provision of private care. Everybody seems to be buying into the current medical inflation rate of 9% per annum, but I am not. I do not believe it has been verified or justified.