James Reilly (Dublin North, Fine Gael)

I am very pleased to respond and reiterate my gratitude to all the parties in both Houses for their support for this Bill. I made it very clear that although this is a requirement of the troika, it is also a measure to which I was utterly committed when in opposition. It is not right that properly qualified GPs are not allowed to treat public patients. I am delighted to bring that day to an end.

Let me comment on some of the matters raised. I am concerned about the out-of-hours service. Generally, it is a very important aspect of GPs' work. If GPs were to abandon it, they would diminish themselves considerably. Many GPs are aware of this. I say this with the caveat that it is not safe to have doctors working night and day. We can address that issue.

I share Senator MacSharry's concern that the Bill could cause a movement towards urban areas, thereby stripping rural areas of service. I have been very careful in the Bill to ensure that one cannot relocate without permission from the HSE. This will avoid the problem. From a policy perspective, we are entitled to support GPs, with additional measures, through grants for nursing, etc., in areas where we want them, be they urban areas such as Tallaght, or certain sections of Fettercairn which have not had a service for quite some time, or rural areas. We do not want the legislation to lead to the establishment of five new GP practices on Grafton Street. So be it if this happens but we will not support them.

I raised the tendency to refer patients to emergency departments in the past. I am concerned about the de-skilling that takes place when a large hospital is built in a general practitioner's area. Equally, I am concerned that circumstances could arise in which locums, in particular, could be inclined to refer patients to hospital for suturing and other work that they should be well qualified to do themselves.

GPs are hard working. They see in excess of 100,000 patients every day whereas the emergency departments see approximately 3,500. They comprise a crucial part of the health service, as it stands, and an integral part of the reform of the health service as we put more work in their direction. GPs will not have to work harder but will have to work in a different, smarter way. They will have to make more use of their practice nurses, primary care teams, physiotherapists, occupational therapists, psychologists, counsellors and others.

I acknowledge the presence in the Gallery of the China Business News delegates and Deputy Flanagan, who is accompanying them.

The relationships between GPs and their patients last for decades, and this represents a great strength. GPs know their patients so well and have an understanding of them, and patients understand their GPs also because they choose the GP they like. There is not a great difference in ability among GPs but a difference in personality. Some people find different personalities easier to get on with than others. If one suffers from depression or another mental illness, there is nothing worse than having to outline one's whole history again to a stranger. It is very comforting to return to the person who knows one's history, physical and mental. This is a real strength of general practice that avoids much unnecessary testing.

The visit over the weekend of Vice President Xi Jinping of China has strengthened our relationship with China. This will be a very beneficial relationship. I very much look forward to our Governments improving the living conditions, health services and economic opportunities of both our peoples.

Senator Burke was concerned about out-of-hours arrangements also. I have covered this but would like to elaborate on it. I am concerned about the sort of work that is being done and the sort of work being referred to hospitals. We need tighter protocols in respect of this and to audit constantly so there will be no slippage.

A HSE survey indicates 90% of the population has access to out-of-hours GP services in 14 centres nationally. Over 2,000 GPs provide services in the co-operatives. They dealt with 931,305 calls in 2009 and 924,000 in 2010. There were 859,778 contacts with GP out-of-hours services up to the end of November 2011. The pertinent figure in this regard is 64,000, which represents an increase of 8% on the figure for the same period last year. People are using the service and it is valuable, but that is not to say it cannot be improved. The breakdown of contracts with the GP out-of-hours service is: 60% GP treatment centres, 29% triage, 10% home visits, and 1% other. Attendance at a treatment centre would usually follow the initial telephone triage. These are not walk-in centres but one can pick up the phone if one is concerned and talk to a nurse or doctor who will offer advice or indicate that a person should come in to see the doctor, or that a person might even need a house call. Funding of €89 million was provided for this service, which represents value for money. If that service was not there our emergency services simply could not cope.

The HSE has carried out a national review which was published in 2010. There is a working group comprising the HSE, the Irish Medical Organisation and the Irish Association of General Practitioners which will continue to implement that review's recommendations. We should have another audit of what is happening out of hours, particularly between midnight and 8 a.m. as regards what is, or is not, being referred.

Senator John Kelly mentioned charging for letters and I can certainly examine that matter in terms of a pro forma system. From my own experience, however, I know that people can be sent by welfare officers, councillors and TDs to visit their GPs for letters. They might be sent back to get a second letter because "two are better than one". This is time consuming, however. Solicitors charge hefty fees for letters so let us be reasonable about this. If the system did not encourage people to seek GPs' letters for various issues perhaps that charge situation could be clarified. The social welfare system pays for social welfare certificates, in a separate contact to GPs, so the issue should not really arise.

Younger GPs who have now come into the system will be willing to work. Let us call it like it is. I know from my own time - and I think Senators will acknowledge this - that when one is in the nest-building phase of one's life, one is prepared to work harder and longer to get money together for a mortgage and raise a family. As one gets older and less able to work those long hours, it is only right and proper that one should not have to do so. I am not saying that younger people should have to do it either, but the opportunity is there for them. Given their energy, they are often prepared to do it. This is where having a good system of new primary care centres comes into play. As I said before, GPs should invest in them where possible. Many people will want to keep their centres open as long as possible, from 8 a.m. to 10 p.m., to get a return on the investment they have made in the building. If that happens, it will take pressure off a lot of other services.

I much prefer the carrot to the stick, so we are working on a fund to allow for the roll-out of primary care centres. We have reckoned that around 200 might be necessary but we are refining that work to see what size these centres should be. We also want to see a roll-out of primary care teams. These would be real teams, rather than teams in name only where somebody receives a letter asking if they are interested and, having accepted that they are interested, they are suddenly part of a team and this is expected to constitute a functioning entity. It certainly does not. I said that we would be transparent around these matters and we will be. We are therefore determined to roll out the centres and teams. I am working hard, as is the Minister of State, Deputy Shortall, to achieve this.

Senator Barrett raised the issue of expenditure. We do spend as much now, and sometimes a bit more, than others. For a long time, however, we underspent and must now catch up. Even when we were spending we misspent, unfortunately, and did not get what we should have received for our money. We now have a great opportunity to address this matter and tackle it. We are 100% committed to doing so.

I agree that the VHI must address its cost base, in terms of its own administration as well as what it pays hospitals, consultants and GPs for services rendered.

I am pleased with the special delivery unit. Under the stewardship of Dr. Martin Connor, it has achieved remarkable things when one considers that for 14 years we threw money at the system and all people could do at the end of the day was throw their hands up in exasperation as the trolley count got bigger. I want to remind the House and the public that in January 2011 we saw 560 people on trolleys, and I said we would never see that again. The special delivery unit has been hugely influential in achieving that. Yesterday, we had serious pressure on the system due to flu and other reasons. At 4.30 p.m. or 5 p.m. yesterday, it looked like we might have up to 500 people on trolleys today if we did not take action. In the past, we would not have had the information because they did not count trolleys at 4 p.m. like we do, and the system was unable to respond. I am happy to say, however, that across the system last night it did respond so that this morning there were fewer than 300 people on trolleys in our hospitals. I think that is worth noting. I want to record my gratitude to those who work in the special delivery unit, clinical programmes and on the front line across the system who made this possible, as well as the management who co-operated and supported those actions last night. It is always a frightening experience to be admitted to hospital for care, but they have made it less arduous for those availing of our health services.