I move amendment No. 1:
To delete all words after "that" and substitute the following:
—notes the recent arbitration award to doctors in the General Medical Service involving a significant increase of 17.5 per cent, implementation to be negotiated in the context of negotiations for the renewal of the 1989 Agreement;
—notes that the review of the GMS Contract has been under way for some time and that, in that context, the Minister for Health has brought forward innovative proposals for the development of general practice which take account of the realities of the budgetary situation and the constraints of the pay provisions of the Programme for Economic and Social Progress;
—regrets the decision by the Irish Medical Organisation to withdraw from the scheme while the review is continuing; and
—calls on the Irish Medical Organisation to withdraw its threatened action and to continue negotiations in good faith in a normal atmosphere free from the threat of withdrawal from the existing Contract."
I am glad to have the opportunity to speak on this motion regarding the current discussions with the medical organistions on the future of the GMS. I sometimes feel that in the intensity of discussions such as these, there is often a danger that we may lose sight of the fact that the patient should be our primary concern at all times. Therefore, let me assure Deputies, at the outset, that while I am confident of a successful outcome to these discussions, in the event of this not happening, the health boards will ensure that free general practitioner services and free drugs and medicines will continue to be available to persons covered by medical cards.
It may be helpful to Deputies if I outline in some detail the background to the present discussions with the Irish Medical Organisation and the Irish College of General Practitioners on the existing contract for GMS services. These discussions are taking place in a review of the services which is chaired by Professor Tom Murphy. This review commenced in March of this year. The 1989 contract, which is the subject of this review, represented a fundamental change in the manner in which general practitioners were paid in respect of services for medical card patients in that it changed from a fee-per-time system to a capitation based system augmented by a range of additional benefits. This change resulted in an estimated 16.5 per cent increase in GP costs. The bulk of these additional costs were attributable to:— a superannuation scheme (with a state contribution of 10 per cent of gross capitation income); payment of out-of-hours consultations; contributions towards the cost of employing nurses and secretaries; contributions towards locum expenses for annual/sick leave, study leave and maternity leave; early retirement arrangements; a doubling of the rural practice allowance and payment for a range of special services which had not been paid for before. Almost 100 per cent of doctors providing GMS services opted for this new style contract on the basis that it would be reviewed after one year and in March 1992. They all signed the new contract.
A review of the first year's operation and the new contract was completed in February 1991 between the Department and the Irish Medical Organisation under the independent chairmanship of Mr. John Horgan. This review covered both the service and financial consequences of the new system and clarified aspects of the original agreement at a further additional cost of about £4 million which was met in 1992.
Last year GMS doctors claimed an increase on all fees of 40 per cent to be paid retrospectively to 1 July 1989. Their claim was heard at independent arbitration in December 1991 and the arbitrator recommended, having regard to the very detailed case made by the Irish Medical Organisation, that these fees should be increased by 17.5 per cent with effect from March 1992 a date which coincided with the three year review of the existing contract. He further recommended that the implementation of the award should be negotiated in the context of that review. The Irish Medical Organisation formally accepted the arbitrator's recommendations on behalf of the GPs.
This award would cost an additional £11 million per annum, which would represent an average of almost £7,000 per doctor per annum, which would be due to be paid on the same basis as all other public service pay awards this year i.e. payment of revised rates on 1 December 1992 and retrospection from 1 March 1992 to be paid on 1 January 1993. The cost in 1993 of implementing this award, including retrospection payments, would be £20 million and the award would increase the average annual payment for doctors in the GMS to about £41,500. This average payment would, of course, only be in respect of the treatment of medical card holders who represent about one third of the population and would not take account of the potential private income available to general practitioners from the population not covered by medical cards.
As I have already stated, the present GMS contract provides for a review of its operation after three years. This review commenced in March this year. The Irish Medical Organisation are represented on the review with the Irish College of General Practitioners, the health boards and the Departments of Health and Finance.
At the outset it was made quite clear to the doctors' representatives that the review would be required to work within the parameters of public pay policy and that the main purpose of the review was to ensure: that a high quality of service was available to medical card holders; that the arrangements for the delivery of services to medical card holders were appropriate, adequate and cost effective; that structures were in place to allow for: the proper management and organisation of service, the control of costs and quality, with particular emphasis on the achievement of responsible prescribing, the effective co-ordination of the service within primary care services generally and effective working arrangements with other general practitioners, with hospitals and other institutional services; that the framework within which general practitioner services were provided for the total population was rational and cost effective in respect of the use of State resources. The review, therefore, would deal mainly with the organisation and funding of general practice rather than simply the payments to doctors.
Since the review commenced, there have been regular meetings both at plenary level and at sub-committee level which have dealt with a wide range of issues such as: the development of general practice, the organisation and management of general practice, prescribing in general practice, workload and expenses, right of entry to the GMS and rural practice. There has been very constructive dialogue on these issues and broad agreement in principle on the way forward has been reached. I assure Deputies that it is my intention to push ahead with the work of the review with a view to resolving outstanding issues through meaningful discussions within the next month.
As Deputies will be aware, I have had many years experience in the health services before I became Minister for Health. In that time I became convinced that many of the difficulties faced by Governments in meeting the increasing expenditure on the health services result from the major imbalance between the primary care and the acute hospital services. Health care delivery in this country is over reliant on the hospital sector where the emphasis is on expensive high technology medicine.
There is no doubt, in my mind, that a great number of procedures now being undertaken at hospital level could be more appropriately and cost effectively carried out by the general practitioner. It is my aim, therefore, to redress this imbalance and to restore the general practitioner to his rightful and central place in the delivery of health care within a fully integrated health care system.
Therefore, I see the development of general practice as a necessary and key requirement for the development of our health services. As part of this development it is necessary to broaden, where appropriate, the scope and depth of the general practitioners contributions to primary care and to improve the interface between general practice and the rest of the health services.
If general practitioners are to adequately fulfil the functions they are capable of fulfilling, the general practitioner service must be integrated with other health services to enable it to function as an integral part of the work of the health board in patient care. I also accept that doctors in general practice provide 24-hour cover for 365 days of the year and restructuring of general practice must take place to take account of this unique service.
To a large extent the difficulties in developing general practice stem from the fact that general practitioners, from an organisational point of view, are separate from the formal structure of the health services, and from lack of structural liaison between general practitioners, management and other sectors of the health services, due no doubt to the fact that they are private contractors to the health services. They contract to provide this service for general medical services patients, as opposed to the position in Britain where they are fully paid by the State for their services. As the House will know, here the medical card system caters for approximately 34 per cent of the population.
In more specific terms organisational and service problems arise from, first, the fragmentation of general practice and the isolation of general practitioners. Fifty-nine per cent approximately of general practitioners operate from single-handed practices with 15 per cent only operating from practices with three or more doctors, making it both difficult and costly to fund desirable developments. For example, general practitioners often work isolated from other general practitioners, or from community care services and hospitals.
Other problems arise from the lack of epidemiological data relating to disease process and morbidity within the community in addition to the lack of a defined practice population.
Since there is no definite list of private patients, the general practitioner in many cases does not know what his total practice population is in terms of either numbers or named patients. In the past, research in Dublin has shown that approximately 11 per cent of families with young children reported not having a G.P. A similar percentage attending at Dublin hospitals Accident and Emergency Departments recently reported having no G.P. at all. In the Dublin setting at least, the general practice population is not stable and a proportion of patients do not closely identify with one G.P. They freely change from doctor to doctor and practice to practice. To add to difficulties in practice organisation, in a proportion of families different members attend different doctors and practices.
Then there is the variation in practice styles. Variable issues include those aspects of the service with which the doctor is comfortable in dealing; what a doctor wants to do and level of investigation within practice. The setting of the practice, whether suburban, inner city or rural and the socio-economic profile of the panel also affect practice style.
Both sides in the review have accepted that general practitioner services should be organised in such a manner that they are capable of delivering a comprehensive level of primary medical care. It has also been accepted that if general practice is to fulfil its full potential: patients must be satisfied that the service available at all times is of a standard that normally avoids the necessity for them attending hospital particularly as a first point of contact; and the service must be seen to be capable of providing care. Therefore, patients and other health carers need to be assured that there is ready access to a general practitioner service which is appropriately equipped and which has satisfactory liaison arrangements with other health services.
Essentially, therefore, we need to shift the focus of health care delivery away from expensive treatment in hospitals to the primary care services and, more particularly, to general practitioner services. However, before such a reorientation can be achieved, the organisational problems within general practice need to be addressed. In this connection, I am satisfied that, if general practitioner services were organised properly, many of the shortcomings identified in the General Medical Service could be overcome; costs and workload would be reduced and funds freed up to allow for investment in the service. These are the reasons a high priority is being given to a resolution of these organisational issues in the current review. In attempting to meet my objectives for general practice, I would envisage that a number of different practice models would be introduced as follows:
First, group practice in urban areas and towns would normally be staffed by a minimum of three doctors in full partnership providing cross-cover for nights and weekends within the group and working from an appropriately-equipped medical centre. Within this centre, there would be facilities for doctors, practice support and other primary care services such as paramedical and social services. Such medical centres would either be provided and equipped by health boards or on a joint venture approach with general practitioners within agreed parameters. The level of equipment and facilities to be funded would be subject to agreement with the relevant health board.
Second, multi-centred group practices would apply in both urban and in rural areas and would involve either: (i) a minimum of three doctors working as a group in full partnership from different locations i.e. a doctor who resides and practises in an area would enter into a full partnership, providing cross-cover, as above, with two or more general practitioners in the neighbourhood. While each would have their own centre of practice, the group would have one central medical centre which would have equipment and facilities available to all members of the group, either by doctors practising there for specific planned sessions or by equipment being borrowed by GPs for fixed sessions. Equipment would be interchangeable between practices on the basis of agreement with the group; or (ii) any number of doctors who are located in proximity to a general hospital entering into a co-operative-type arrangement. All doctors in the arrangements would continue to operate from their own centres of practice but would agree to pool all resources, including staffing and equipment, and to provide full cross-cover.
Third, where group arrangements are not workable, for example in isolated areas, one or two-handed practices would be recognised and supported by the provision of incentives, provided arrangements acceptable to the health board are made with other practices for night and weekend cover. Access to equipment in group practices by these doctors would be encouraged.
In the case of all these arrangements it is recognised that a general practice requires support structures such as nurses, secretaries and access to sessional arrangements for various paramedical services and to a range of diagnostic and treatment facilities. Of course, the range of support structures necessary would be dependent on the type of practice arrangement entered into. I should say that, whenever a doctor would be given a grant towards the cost of a practice nurse, he would be paid in respect of the proportion of his practice only applicable to medical card-holding patients. He would not be paid a full secretarial salary if a proportion of his patients only were general medical service patients. Many doctors who never had secretaries before availed of the grant but, of course, incurred extra costs because they were provided with a proportion only of the secretarial salary in respect of their medical card patients.
A major portion of expenditure within the general medical service scheme relates to the cost of prescribing which in 1991, amounted to £120 million and which we expect to rise to over £130 million by the end of this year. As a result of the agreement drawn up between the Federation of Irish Chemical Industries and my Department, drug prices have remained stable here over the past two years. Notwithstanding that stability in prices, expenditure on prescribed drugs within the general medical service continues to rise as a result of increasing volumes of drugs being prescribed and the substitution of newer, more expensive drugs for older cheaper ones. These trends are an international phenomenon and are not unique to this country. Nevertheless they place heavy demands on the Exchequer and limit the scope for investment in general practice.
It has been accepted by the Irish Medical Organisation that the level of prescribing within the scheme could be reduced without any adverse effect on the quality of patient care. It has been agreed also that indicative prescribing targets should be determined for all doctors participating in the scheme, that is, indicative prescribing targets which are realistic. I readily admit that indicative prescribing targets were set for doctors, I think two years ago, which were totally unrealistic and which created great problems for them. Realistic indicative prescribing targets should be determined for all doctors participating in the scheme and a proportion of any savings generated from the operation of these targets should be applied toward general practice development.
I also hold strongly that a greater contribution toward the development of the public health services could be derived from other sources. In fact I would be very confident that such an increased contribution would materialise very shortly. I am heartened by the level of goodwill shown by the Irish Medical Organisation and the Irish College of General Practitioner representatives towards the establishment of measures aimed at achieving rational prescribing. I am confident that, arising from this review, workable arrangements will be put in place which will introduce more cost-effectiveness in this area.
In broad terms, therefore, my main priorities in the GMS review are the strengthening of the role of the general practitioner to enable a comprehensive primary care service to be provided for persons covered by medical cards; improving the interface between the general practitioner and the hospital and other institutional and community services; encouraging the development of more group practices and better cross-cover between existing practices in order to enhance the continuity of care for patients; and implementing measures which will result in safe and cost-effective prescribing. As I said these priorities deal with the service issues including the adequacy of the funding for general practice rather than simply payments to doctors.
I fully recognise the major role played by general practitioners in the overall provision of health care and I have been anxious in the review, to identify areas where their contribution could be enhanced in a cost effective way. Proposals have been put to the doctors which will significantly improve the quality and standard of general practice. Deputy Owen accused me of not bringing forward proposals. I would suggest that she listen to me. Of fundamental importance is that these proposals offer general practitioners, for the first time, a central role in the day-to-day functioning of primary health care services at both national and local level. I advise Deputy Owen to read the blueprint for general practice which emanated from my office. She would learn a great deal. I see these proposals as representing a blueprint for the development of general practice here over the next decade and I envisage that future GMS contracts will fit in with the strategy outlined in this blueprint. It is certainly encouraging that we have now reached a stage in the review process where agreement in principle has been reached on these proposals which I am glad to say both sides accept will be a major step forward for general practice. We should have a little less ráméis and a greater understanding of what is going on.