Alex White (Dublin South, Labour) | Oireachtas source

I thank all the Senators for their extremely helpful contributions on these amendments and I will address some of the specific matters raised shortly. As agreed by Members, amendments Nos. 1 to 7, inclusive, are being taken together. These proposed amendments seek to insert new sections after section 5, which effectively seek to determine the shape of the GP contract for the provision of services to children aged five and under. With respect, it is not appropriate to include provisions in legislation that would restrict the terms of any agreements which the HSE may enter into with GPs for the provision of services to children aged five and under, as provided for in the proposed section 58C(1) in the Act of 1970.

Members will be aware that the Department of Health and the HSE are currently in discussions with the IMO within the context of the framework agreement I signed on 4 June last. This framework agreement sets out a process of engagement on all aspects of the GMS contract with GPs with due regard to the IMO’s representative role and within the context of legislation underpinning the introduction of GP care free at the point of access. Substantive engagement with the IMO is under way with regard to the draft contract for the provision of services to all children aged five and under. Under the aforementioned framework agreement, the IMO can fully represent its members in respect of discussions around all aspects of this draft contract, including fees, and in respect of the GMS contract. That is the appropriate forum to address the concerns of GPs concerning the draft contract, which was published on 31 January 2014.

I do not propose to accept the amendments proposed by Senator Crown.

Amendment No. 1 is clearly prompted by what has been referred to as a gagging clause in the draft contract. The specific clause in the contract as published, which is clause 28.4.4, was intended to reflect and be protective of the HSE's interests given that the primary statutory obligation to provide general practitioner medical and surgery services will rest with the HSE. It is not in any sense intended to impose unwarranted or inappropriate restrictions on individual GP contractors advocating on behalf of their patients. The clause in question should be viewed in the context of the entire draft document where the intent is to balance the duties, obligations and rights of both parties while at the same time having due regard to the overriding statutory obligations that will rest with the HSE. Nevertheless, in view of the reaction to this clause in particular, the HSE and the Department are willing to discuss the matter further with the IMO. There is no intention on my part or on the part of the Department, the Minister or the HSE to effect the kind of restrictive environment that seems to be suggested in the amendment.

While I do not propose to accept the amendment, I am sympathetic to the thrust of the points the Senator made. It would not be appropriate to restrict criticism, impose obligations to limit criticism in the kind of circumstances he outlined, require a GP to notify or get prior approval from the HSE in advance of saying something or in any way dilute the natural right to freedom of expression implicit in the Constitution. Although I have huge respect for the Members of this and the other House, I do not think it is appropriate or even possible for them to manage the negotiations on this contract. I say that with all the respect that is due to Members. Negotiations on any contract are a matter for the parties involved and that is how matters should proceed. I accept that there are concerns about the aforementioned clause. The Department and the HSE are committed to addressing such concerns and, for my own part, I believe the matter can be resolved to the satisfaction of both parties.

Section 58C deals with the contracts the HSE may enter into with GPs for the provision of GP services to all children aged five years and younger. Subsection (1) provides that the HSE may enter into a contract on such terms and conditions as it considers appropriate, and subsection (2) provides that the contract shall specify the services to be provided by the GP. The proposed amendment No. 2 seeks to ensure the contract shall not include greater specification of services to be provided by the GP than is included in the GMS contract. The draft under-six contract encompasses the strengths of the existing GMS contract while also seeking to address, in so far as is practicable, its weaknesses and limitations. This new draft contract provides a unique opportunity to refocus primary care towards prevention and health promotion, in addition to diagnosis and treatment. It is wholly appropriate that a contract being introduced in 2014 should reflect the requirements of today rather than simply reflecting the terms of a GMS contract introduced 25 years ago. If the amendment were accepted, it appears it would confine the services to be offered under it to those already provided. I do not regard that as appropriate and I am not prepared to accede to such a proposition.

In regard to amendment No. 3, when drafting the contract consideration was given to the document, Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025. This is the Government's national framework for action to improve the health and well-being of the population over the coming generation. Based on international evidence, it outlines a new commitment to public health with an emphasis on prevention and stronger health systems. This is related to Senator Quinn's point on China. It addresses risk factors and promotes protective actions at every stage of life, including early childhood. Healthy Ireland has been informed by feedback from an extensive consultation process with Government, the health sector and the wider public and provider society. It reflects international experience and evidence of what determines health and reflects best practice on how to prioritise and invest for long-term sustainable health benefits. A key feature of the draft contract is to refocus primary care towards prevention and health promotion, in addition to diagnosis and treatment. As well as ensuring equitable access for young children to health care, GP care without fees will reduce the financial burden on young families, many of whom face unemployment and negative equity. It also increases the likelihood of conditions in children, such as obesity, being identified and addressed at an earlier stage, and of vaccination rates being maintained. A broad range of evidence from the international scientific literature attests to the value of health checks and health-promoting activities for issues such obesity in early childhood. The detail of the relevant clause of the draft contract, that is, clause 13, will be discussed with the IMO within the terms of the framework agreement referred to.

Perhaps Senator Crown will disagree but to say there should not be annual or periodic assessments is tantamount to saying there should be no assessments. It is problematic, at the minimum, to suggest we should not have health assessments of persons who are healthy. That may be a point of disagreement between us but I think it would be inappropriate to exclude such assessments from the remit of the contract. This is intended to be a contract with GPs but not all the services we are proposing to contract with a GP need to be carried by that individual. This issue turns on the configuration of staffing and resources for general practice. Practice nurses and many other well-trained primary care professionals are capable of carrying out much of this work. If the contract is for the provision by the GP of a service, he or she does not have personally to perform all the individual actions required, whether they involve weighing a child or taking bloods. Many of these tasks can be carried by other trained primary care professionals. However, the contract for delivery of the service is with the GP.

Amendment No. 4 refers to the contract duration. The draft contract proposes a contract duration of five years, with the option of extending it for further periods of five years subject to satisfactory outcome of performance reviews. Performance reviews are a widely recognised feature of contracts for services and for this reason they have been included in the draft contract. To the extent that there is a concern about restrictions in the number of years, that is amenable to negotiation and engagement among the parties to the contract. It is wholly unsuitable to suggest some form of statutory intervention into the matter. It should and will be a matter for discussion with the IMO.

In respect of amendment No. 5, clause 13 of the 1989 contract includes minimal requirements for practice premises. For example, the contract requires a waiting room with a reasonable standard of comfort and hygiene sufficient in size to accommodate the normal demands of the practice for both eligible and private patients with adequate seating.

Second, a surgery sufficient in size for the requirements of normal general practice, with facilities, including electric light, hot and cold running water, an examination couch, and other essential needs of such practice, including a telephone. That is the existing position.

Clause 12 of the new draft contract seeks to build on these requirements to reflect current needs and expectations. However, I again emphasise the comments received as part of the public consultation process and those made today concerning practice premises and the term of the contract have been carefully noted and these issues will be discussed further with the IMO. In regard to the plain intent of amendment No. 5, the Senator is perhaps unintentionally calling for a situation where there would be no minimum requirements set for practice premises. That would be a regression because it would seem to suggest that even the minimum requirements there currently ought to be removed as it has been suggested there should be no restrictions.

In regard to amendment No 6, I emphasise there is no intention to interfere with the doctor-patient relationship and the contract will not provide for any inappropriate sharing of patients' medical information. This was raised in recent months and it will be discussed with the IMO. Any concerns as to what is intended can be addressed in that context. I will return to the matter in a moment, if I may.

In regard to amendment No. 7, section 58C provides that the HSE will be entitled to enter into a contract with any suitably qualified and vocationally trained general practitioner for the provision of GP services to all children aged five years and younger. The requirement is that a doctor is registered on the specialist division of the register of medical practitioners and holds a current certificate of registration in respect of the specialty of general practice. This is not new as the Health (Provision of General Practitioner Services) Act 2012 includes the same requirements.

However, the Bill provides that the HSE may enter into a contract for relevant services with any registered medical practitioner who already holds a GMS contract for the six-month period following commencement of the section. This is in recognition of the fact that some older doctors, while fully qualified, may not have registered on the specialist register. The draft contract includes a reference to English language competency but, I would respectfully say, there is no need to go in to this level of detail in the legislation.

The 1989 contract includes procedures concerning complaints, suspension and termination of the contract. These are important features of any contract. However, the draft under-six contract includes a more comprehensive, practical and fair set of processes and procedures, including disputes resolution arrangements. These arrangements will be the subject of further discussion with the IMO.

I wish to respond to some of the points I may not have fully addressed. The House would expect me to say, but I want to emphasise it, that there is no intention in anything we propose to do in this legislation or elsewhere to undermine or still less, to use Senator Healy Eames's phrase, to dismantle our system of primary care and our system of general practice. Why would we do such a thing? Why would we have such an objective? It is absurd. We seek to improve and enhance primary care and the provision of our health service. Everybody in this House wants to achieve the same objective. We may disagree about some of the policy choices but there is no wish, in any sense, to undermine what we do.

There is ample evidence that fees at the point of delivery for general practice constitute a significant barrier to attending one's general practitioner. This is not just my assertion. The evidence is very considerable. People, even relatively well-off people, put off going to see their doctor because of the barrier of fees and I have read studies on this. People like me and most Members of this House, who are not medically trained, are not in a position to make an informed decision as to whether we need to go to see a doctor. I would say with respect to Senator Quinn that sometimes the issue of the market intervention or the fact there is a fee and a commercial relationship enters into that dynamic and I would respectfully submit that it should not. I am not opposed to the market determining distribution of services and resources in different parts of the economy and society but perhaps this area is arguably wholly unsuitable to the question of how one distributes and facilitates the distribution of health care.

The fees have been shown demonstrably to be a barrier to attendance. As people do not go to see their doctor, because they do not wish to pay €50 or €55, we cannot begin to encourage them to come into primary care for the preventative strategies we want to put in place in primary care. Who will go to see his or her doctor about a problem he or she thinks he or she might have in 20 years' time? Who will go to see his or her doctor to say he or she thinks he or she might be a candidate in ten, 20 or 30 years' time for diabetes? Who will pay €50 or €55 for that exercise? It is very unlikely people will do so.

We use the term "free GP care". I was criticised for making the following comment in the media. I said I accept - I think this will please Senator Barrett - that nothing is free because it has to be funded. It is a decision by society and by the Oireachtas as to whether it is appropriate to fund something or not. We have the honour to be here and to be the people who decide on that. We use short-hand terms such as "free GP care" but we know it has to be funded. I believe it is absolutely something that deserves our taking steps to introduce.

I understand Senator Healy Eames's point that she agrees with universal access in theory. By extension, it seems she is making a distinction between agreeing with it in theory but not necessarily agreeing with it in practice. Our challenge, if we agree with it in theory, is to bring forward that policy in the way the Government has decided in the programme for Government and in its subsequent decisions in that regard.

I addressed the issue in regard to GPs and I agree with Senator Crown. Who better to make the point than he about the importance of advocacy and the professional independence and autonomy of doctors, general practitioners, medical specialists and others to do the job they do but also to be in a position to advocate on behalf of their patients, patient groups or on any issues they regard as important that should raise, whether in this House, outside it or anywhere else. I am a strong believer in that. I am also a strong believer that doctors and medical people should have the right to do that and should not be restricted in that regard. One can take whatever one wishes from what I have said but one can take it that it is certainly my view and that of the Minister for Health.

There is no intention to interfere with doctor-patient confidentiality. If Senator Crown is right that there is some sloppiness in the wording of the agreement - I am not quite sure where he finds that sloppiness - we can address it in the course of the engagement underway with the IMO.

In regard to Senator Colm Burke's questions on insurance cover, the draft contract includes provisions on warranties and indemnities. It will also be the subject of discussion with the IMO because it would want to address that with us. On the legislation in respect of a requirement to have insurance, I am advised drafting of that legislation is continuing. I hope we will be able to repot progress on that soon.

Senator Gilroy made a point, reflected in the remarks of other colleagues, that the very real concerns of general practitioners throughout the country must be respected and taken on board. Senator Healy Eames and others made that point also, with which I agree. However, things have moved on since some of the meetings to which Senator Healy Eames referred. I heard about those meetings, know a lot of what was said at them and have read what was said in the media in respect of them. Things have moved on considerably.

I spent some weeks negotiating an agreement with the IMO. I emphasise the agreement is not an agreement on the contract but on how we do business together.

We needed to do that, arising from the uncertainty and difficulty associated with the competition law environment. We have now secured an agreement with the IMO which will facilitate a good competition law-proofed way of engaging the State services with the general practitioners, GPs. I am confident that will facilitate a very good level of agreement between ourselves and the doctors, which is necessary, and I agree with colleagues on that. Senator Quinn said there should be negotiations on this and engagement with people. There will be. Such negotiations and engagement are under way.

It is very easy to fall into the trap of decrying and criticising bureaucrats. I understand the frustration people sometimes feel, not just with the health services. We need good people to administer our health services. Of course we need doctors and medical professionals but we also need people to administer the service and to work on issues such as the contract. There is overarching political involvement in it but there are very engaged, professional people in the Department of Health and the HSE who worked hard to put in place the draft contract and then listened to, and engaged with, the GPs and the doctors. I assure the Members of this House that is happening.

These people, who do a terrific job on this, are entitled to a little more support than they sometimes get. I am not necessarily talking about this House but more broadly. The quick dismissal of bureaucrats is often misplaced. It is not a question of gratuitously wanting to interfere in general practice or to arrive in the dead of the night to go through everything in the surgery to see what people are doing, to look around corners, correct GPs homework or look into their computers for no apparent reason. That is not what anybody wishes to do. There will be no interference with the professional autonomy of doctors, whether in regard to data or any of the other aspects of the contract. It is simply a case of getting it done properly and economically on behalf of the State. That is what we intend to do.

I agree with Senator Barrett’s point that GPs ought to be available outside what we normally regard as working hours. Most general practitioners will say that there is such a service. There are good cooperative services in most, if not all, parts of the country now. GPs are not confined to nine to five hours. They work at different times in the evening and weekends as well. I agree with him that it is right that we should go for practices of four or more GPs. The model of the sole practitioner, whether in an urban or rural area, is in decline for good reason. It is not economically possible to sustain that model. That is why we are developing primary care centres.

I was interested in Senator Barrett’s point about the edifice complex. One thing that saddens me about health care is that people talk about hospitals only, defending them against closure. I might be on the streets if I lived in a town where the hospital was going to close. I would love to see the politics of health care moving to advancing, and advocating for, primary care services in the community.

I was in Schull in west Cork to open a primary care centre a few weeks ago. This is transformative for a relatively remote area. People no longer have to make a 100 km round trip, whether to Bantry or somewhere else, to go to an acute setting for example, to have a wound dressed, or something else done that should be done in the community. It has a transformational effect on the way people access health care because having to get on the road and travel is one of the most stressful things for people who are ill and vulnerable. While Senator Barrett is right about the edifice complex, I would seek support for a different type of edifice, a small primary care centre that combines under one roof, GPs, physiotherapists, speech and language therapists, and all the other health care professionals collaborating and working together so that people do not have to go to the much bigger edifices. We can then transform our health care services in the way we want that to happen.

We had an exchange the last day we debated this Bill, about the universal aspect, of which Senator Barrett is at the very least sceptical. I respectfully continue to disagree with him on that point. We are an outlier, compared with any country in Europe or the Organisation for Economic Cooperation and Development, OECD, where primary care does not have the commercial barrier of requiring one to pay fees. We must remove the barrier of fees in primary care so that people do not have to go to the accident and emergency department in the hospital. We should do that universally, for all our citizens. We need to find ways to do and fund that as quickly as we can.

Senator Barrett said the GP service works well, and Senator Healy Eames and others pointed out that it is the one part of our health service that is working well, and asked why interfere with it. Taken in isolation I agree it is working well but the health system is not working well. We have to look to primary care as the engine of change in the health service. Whereas one can say without fear of contradiction that the GP service is working well, it has to change in order to help the rest of the system to work well. That is why we are pressing for the expansion of primary care. The broader system is not working well and primary care is the way to go to resolve so many of those issues.