John Crown (Independent)

I welcome the Minister to the House. I also welcome his presence in the Department as he brings to it the zeal of a reformer, something sadly overdue in the health service. We look forward to supporting him in his efforts to forge real reform.

I welcome this important Bill because there was a problem with the structures for entrance into general practice which was having negative downstream effects on the service delivered to patients. This legislation will remedy this and increase the ease with which suitably trained and experienced doctors can get access to general practice. It will also improve the access of patients to highly qualified general practitioners. There are several demographic trends which suggest we could run into a serious shortage of GPs in the future. Even if that were not to occur, it is natural justice that these reforms should take place.

Ireland has the lowest number of general practitioners per head of population of any western country. In general, a low number of GPs per head of population means either the country has an underdeveloped health service or there has been a subtle internal professional rebalancing between primary and secondary care as happened in the US, which has a relatively low number of general practitioners but a large number of specialists. People in the States tend often to go directly to specialists or other physicians and surgeons when they have medical problems. In Europe, we tend to go a general practitioner first. When one looks at the global figures of GPs per head of population, one will note those countries which follow the more liberal Bismarckian welfare system model tend to have relatively large numbers of GPs. The NHS model is anchored near the bottom while its "Mini-Me", the New Zealand health service which apes the NHS so flatteringly, is even lower. Then at the bottom are ourselves. This reforming legislation will go some way in fixing that.

We should reflect on the differences we have in this country between general and specialist practice. We have a much more functional general practice system with only one problem - the bottleneck at entry of new GPs into the system. When that bottleneck is lifted, we will see the full flowering of a good general practice system.

I have minor quibbles with the way GPs are trained. In my ideal world, the ludicrous division between hospital-based doctors and GPs would be done away with. Having a highly experienced GP sending a patient to hospital to have an opinion given by a trainee doctor is crazy. Our GPs should be fully integrated into the hospital community, admitting patients to hospitals and doing rounds on their own patients. GPs should be more like the American internalist. While this is not the forum for a debate on the minutiae of how GPs are trained, I would see a certain logic to having general practice slightly split between adult and paediatric practice and a cohort of hybrids between adult general practitioners and internal medicine physicians who would have a practice which would be largely ambulatory and domiciliary but have a hospital basis.

The greatest difference that stands out in our general practice service model is that while GPs are paid two different ways for the patients they see, general practice care is single tier. Public and private patients will attend the same practices during the same times, sitting in the same waiting rooms. There are not separate times for private and public patients. The magnitude of reforming the health system is not that large and can be done because it has been partly done in general practice already.

One key issue which I believe the Minister will safeguard during his long tenure unless he gets promoted-----