Dáil Éireann debate -
Tuesday, 6 Dec 2016

Vol. 931 No. 3

Medical Practitioners (Amendment) Bill 2014 [Seanad]: Second Stage

Minister of State at the Department of Health (Deputy Finian McGrath)

I move: "That the Bill be now read a Second Time."

I am pleased to have the opportunity to address the House on the Second Stage of the Medical Practitioners (Amendment) Bill, as passed by Seanad Éireann. The purpose of this Bill is to make it mandatory for medical practitioners who are engaged in medical practice to provide evidence of minimum levels of indemnity insurance cover to the Medical Council. They will do this when they first register with the council and thereafter on annual renewal of registration.

There are currently approximately 20,000 medical practitioners on the Medical Council’s register. However, there is no legal obligation on a medical practitioner to have medical indemnity insurance cover. In some cases also medical practitioners may have indemnity cover, but this cover may be inadequate for the specialist area in which they practise. As a result, some patients and the users of medical practitioners' services may find they are unable to seek redress in the event of a medical mishap or negligent care from a medical practitioner. Given the high cost of litigation and the long-term consequences of some adverse events, this legislation is to be welcomed as patient-focused and progressive.

The main purpose of the original Medical Practitioners Act 2007 is to protect the public and to have a proactive system of robust registration and regulation of the medical profession in order to minimise the risk to the public and to safeguard the health and well-being of people accessing health services. Under the Medical Practitioners Act, the Medical Council must register every medical practitioner who practises in Ireland. In anticipation of the enactment of this Bill, the council already asks medical practitioners on application for registration and on annual retention of registration whether they have indemnity cover. On the enactment of the legislation, medical practitioners will not be registered to practise unless evidence of adequate indemnity cover is provided to the council. This development can only be to the benefit of patients.

The Bill, as originally published, put an onus on the Medical Council to specify minimum levels of indemnity on being advised by the State Claims Agency of what these levels should be. However, it was agreed on Committee Stage in the Seanad that the Bill should be amended to make it explicit that it would be the State Claims Agency which would specify minimum levels of indemnity. Currently, the State Claims Agency's functions relate to the management of clinical claims under the clinical indemnity scheme and so it has the expertise, knowledge and experience in this area. It also has close contacts with private medical indemnifiers, insurers and other experts in the area of clinical negligence and risk. It is, therefore, very well placed to assess and specify the minimum levels of indemnity which should be required by medical practitioners. This policy change required that a new function be given to the State Claims Agency under section 8 of the National Treasury Management Act 2000, as amended.

On 5 June 2015, Government approved the drafting of amendments to the Bill. In the current Bill, the State Claims Agency will link with relevant bodies in order to assess and specify what the minimum levels of indemnity should be for medical practitioners in different specialties on the Medical Council's register. There are currently 58 medical specialties on the register. Practising in some specialties has an inherently higher risk of a medical mishap than practising in others. Even within different specialties, some types of medical practice, by definition, will have a higher risk than others. The State Claims Agency will specify the indemnity levels to the Medical Council, which will check the indemnity cover held by each medical practitioner on the register. It is important to point out that all doctors who work in the public health system are provided with medical indemnity insurance under the State's clinical indemnity scheme. Likewise, private consultants who practise in public hospitals are also covered by this scheme.

However, doctors who are engaged in fully private practice in private facilities must purchase private indemnity insurance cover. There is a wide range in the cost of cover for consultants engaged in private practice. For example, a consultant practising dermatology, based on figures from medical indemnifiers, would be considered low risk. The annual premium for this practice could be around €16,000. However, a spinal surgeon may have to pay over €100,000 for annual medical indemnity insurance cover, reflecting the much higher risk involved in that practice. The Joint Committee on Health and Children heard last year how the cost of cover for medical indemnity in private practice has increased significantly in recent years. For example, the increase was around 42% in 2014. The reason given by the medical defence organisations for this increase is that it is mainly due to the high cost of awards for clinical negligence in Ireland. This is supported by the increasing cost of clinical claims under the clinical indemnity scheme. In 2014, the cost of the scheme was €106.2 million but in 2015 this had risen to €187.7 million. The cost in 2016 is expected to be over €220 million.

The legislation will not require medical practitioners to pay any more than would be the normal adequate cover for the type of medical practice in which they are engaged. A medical practitioner who is not engaged in medical practice does not pose a risk to another person relating to his or her medical practice and so does not need cover. For example, a practitioner who is a full-time lecturer and who is not lecturing in a clinical specialist area will have no legal obligation to have medical indemnity insurance cover.

The legislation is one element of a package of measures being introduced by Government relating to medical negligence. Other elements include legislation on pre-action protocols for clinical negligence cases. This forms part of the Legal Services Regulation Act 2015, which was enacted by the Minister for Justice and Equality. That legislation should help shorten the time that it takes for clinical negligence cases to go through the courts. In addition, the heads of Bill on periodic payment orders, which will form part of the civil liability (amendment) Bill, have been agreed by Government and this legislation will be published shortly. These tort reform measures are being accompanied by a range of patient safety measures aimed at reducing the risk of clinical incidents happening in the first place. Patient safety and quality must be at the heart of our health services and it is important to keep our patients and service users at the centre of everything we do. Delivery of health care is, however, inherently risky, and while it is inevitable that things go wrong, there is much that can be done to prevent harm or error, identify the cause when it occurs and learn from this to improve services.

My Department is fully committed to progressing the programme of major patient safety reforms agreed by Government last November. These measures are focused on legislation, establishing a national patient advocacy service, introducing a patient safety surveillance system, extending the clinical effectiveness agenda, establishing a national patient experience survey and a national patient safety office in the Department and setting up a national advisory council for patient safety. Within the programme of legislation, we intend to progress the licensing of our public and private hospitals, the health information and patient safety Bill and provisions for open disclosure.

I hope Deputies will support this important Bill. Given the trauma faced by patients and their families when things go wrong, there will at least be clarity that medical practitioners have adequate minimum levels of medical indemnity insurance cover. I thank Senators for approving the Bill and for checking on Committee Stage that the legislation was robust and fit for purpose. I commend this Bill to the House.

Deputy Billy Kelleher

Fianna Fáil will be supporting this Bill and welcomes the fact that it is before the House for debate. This has been a long time in gestation. It has been discussed for a long time in various Dáileanna over the years and there have been Private Members' Bills on it as far back as 2007, if memory serves me right. We are now in a position where we can move this legislation through the parliamentary process. It is important that the public has full confidence when it avails of medical services in the State, be they in the public hospital or health care system or the private health care sector. This Bill will address those issues. The fact that people must register with the Medical Council and show they have adequate indemnity cover is very welcome.

The Minister of State said that the State Claims Agency will assess what the required indemnity threshold will be for the various specialties and sub-specialties in the private sector. This is something we welcome. However, we do not want too much delay or prevarication on the part of the State Claims Agency in assessing what is considered acceptable cover and then referring it to the Medical Council for it to be included in the criteria for the registration of clinicians, physicians and others. It is alarming that there is no legal requirement for indemnity in the private sector. This has caused difficulties for individuals who have had to take cases and find that there is no cover available to them in the normal process when harm is done to them.

That is certainly of grave concern. We have seen that in certain areas. Cosmetic surgery, in particular, has caused considerable difficulty for certain people in recent times, leading to class actions, etc.

Of course, this is just one of a suite of measures to be introduced. The issue of open disclosure and duty of candour is another key area in ensuring that there is confidence in the system and that it is not as adversarial as at present. If damage is done to an individual we need to have a system in place. While accepting that clinicians have an entitlement to defend their professional integrity, dragging people through a very onerous and confrontational legal system is distasteful, to say the least, particularly when harm has been done to them.

While we must all come to the pre-legislative scrutiny with open minds on open disclosure, it is something that needs to be not just written in legislation but also instilled in the culture. If there is an adverse effect on an individual who has had interactions with the health system, public or private, there should be an onus to accept, inform and make redress without the usual delay, prevarication and, sometimes, a very hard-headed legal process for people to overcome in order to seek redress. I welcome that aspect of the provisions that are coming.

It is alarming - the Minister of State referred to this in his speech - that medical indemnity insurance costs have increased by 42% in the private health care sector. Under the clinical indemnity scheme, payments have doubled in two years, from €106 million in 2014 to an estimated €220 million in 2016. Of course, that has an impact all the way back to people who are taking out private health insurance. It impacts on people who are trying to maintain private health cover because these costs are ultimately borne by people who take out private insurance and use private health care facilities.

We need to look at this area very quickly to understand the reasons behind it. Over the years in various Oireachtas health committees we have had discussions about the indemnity, the costs of the awards and all that flows from that. If damage is done, obviously there must be redress, but we need to ensure that our payments systems are in line with best international standards and practices in similar legal systems to ours.

Damage was done to people in Our Lady of Lourdes Hospital in Drogheda and in some other areas over a number of years. When discussing issues like this we must acknowledge that some people have been treated very poorly by the system, in the first place when they interacted with the health services. Subsequently it sometimes takes the State a very long time with huge resistance to redress. That applies not only to the health area, but also to institutional abuse where the State has put up huge resistance where by and large it is accepted that a wrong was perpetrated to an individual or a group of people.

At times the State does itself a disservice by being too entrenched by trying to defend a position that is no longer defensible. If we expect open disclosure and a duty of candour from individuals working in the health system, then the State should equally be obliged to have an open disclosure and a duty of candour to ensure that individuals are not put through onerous processes. I accept that the State has to defend its position, but the State for many years has defended positions that were wholly indefensible. With almost infinite resources and taxpayers' money available to it, the State has fought citizens tooth and nail to the steps of the Supreme Court, knowing full well that at the end of the day that it would lose. It was simply a policy of prevarication and obfuscation. We need to change that if we are to have a true republic where citizens have an entitlement to at least due process and equal opportunity in trying to seek redress as opposed to taking on a state that has and uses very heavy-handed tactics from time to time.

While not wanting to delay the House too much, I wish to broaden the debate. We welcome the Bill, which is significant in many ways. There is, of course, an issue with the number of clinicians, doctors, physicians and other medical professionals coming into the country. We need integrity in the process. We are doing not just ourselves but global health a disservice by not training enough of our own doctors and nurses. We have a dearth of highly trained professionals in this country, while some of our best and brightest are leaving. At the same time we are going to the poorest countries to pillage their best and brightest. These people are needed in their own countries.

There is a moral imperative here. As the First World country we claim to be, we are consistently trawling the world looking for nurses and doctors from elsewhere. At the same time we will not train enough in our own system and many of those we train are leaving. From a moral and ethical point of view that needs to be addressed. If people want to come here and feel they have something to offer, they are more than welcome. However, we need to address the moral and ethical issue of a First World country going out and basically taking people from countries that need them badly. We are targeting countries with a series of recruitment advertisements, while nurses and doctors trained here are going elsewhere - primarily to other First World countries obviously. We then leave a dearth in the countries from which we get them with no obligation on us to assist them in any way. As a country, we should think long and hard about that. I am very liberal when it comes to opening up our labour market to people from outside and I have always welcomed that. I believe we need to discuss the medical area because it has an impact on their home countries.

In looking at the suite of measures, we need to ensure that the State Claims Agency robustly, efficiently, effectively and quickly assesses the type of indemnity required for the various specialties and sub-specialties. Equally we need to assess the impact the clinical indemnity scheme and the pay-outs is having on the cost of health cover and the provision of private health care in the country. In the overall health service - public and private - open disclosure and a duty of candour needs to be not only addressed statutorily but also embraced as a cultural shift in thinking.

Overall I welcome the concepts behind the Bill. We need to move quickly to assess what is required to implement it, ensuring that the resources are available to the State Claims Agency. We often pass legislation here without providing the agency that has to make the assessments and implement it with the resources to do its job effectively. It is critically important that whatever measures are required are available in supports for the State Claims Agency to make these assessments to ensure the Medical Council has full knowledge of what indemnity is required.

Deputy Louise O'Reilly

I note that my colleague, Deputy Ó Caoláin, spoke on this legislation in January of this year and that it has taken us almost a year to come back to Second Stage. I welcome the opportunity to discuss this legislation and other issues relating to the medical profession and safety in our health system. We have been told that this legislation is designed to protect the public and to have a proactive system of robust registration and regulation of the medical profession in order to minimise the risk to the public and to safeguard the health and well-being of people accessing health services. The legislation is supposed to do this by making it mandatory for medical practitioners engaged in medical practice to provide evidence to the Medical Council of minimum levels of indemnity insurance cover on registration with the council and on annual renewal of the registration.

While researching this legislation, I noted with interest that issues relating to medical negligence and clinical negligence cases were central to this and to other upcoming legislation. This struck me because I see our health system as being under-resourced and having capacity issues and an inability to recruit and retain staff. These issues are the greatest enabler of medical or clinical negligence currently. While we are legislating to ensure that medical practitioners are sufficiently covered, we are not making enough strides to ensure that the health system is robust enough to offset potential incidents. This is what we are discussing, namely, the likelihood, or otherwise, of these incidents occurring. For example, the Minister might take the frequency with which the full capacity protocol is being deployed in our hospitals. It was deployed 2,300 times in a 321-day period in 2016 across 26 hospitals. The protocol of last resort is now being used with such worrying frequency that alarm bells must be going off in the Department of Health about the lack of capacity. Yet, despite the Government rhetoric of there being the largest investment in health in years - I have heard so many times about the largest investment ever in the history of the health service - it seems this is not enough. Even as we sit here this evening, the full capacity protocol is being overused. The full capacity protocol should indicate that a hospital has breached maximum capacity but it appears to be a constant state for many of our hospitals now.

With accident and emergency departments overcrowded, people languishing on trolleys and understaffed services across all parts of the health service, how can we expect that we can deliver quality, safe care without any incident? We see nurses and midwives balloting for industrial action in some areas, precisely because they do not have the confidence in the services. The decision by INMO members to commence industrial action is based on their concerns in regard to patient safety and their ability to provide safe care. These concerns are well known and have been articulated in the media many times. It is a great concern to front-line midwives that the ongoing clinical risks due to a shortage of staff remain unaddressed. What is the Minister of State doing to address this? I am sure the Minister of State would agree that in order to make the health system patient-focused and progressive, as previously stated, these issues must be addressed urgently.

I would like to use some of my time to refer to another matter, albeit a slightly tangential one relating to general practitioners. From deliberations we have had in committee with the Minister for Health and officials in the HSE it is clear that preparations for the next phase of the discussions on a new GP contract are under way. Similarly, as I have read in the newspapers and elsewhere, the HSE has commenced a comprehensive public and stakeholder consultation process. I raise this issue because of the current dispute and problems surrounding Shannondoc. I am very cognisant that there are many facets of the GP contractual relationships with the HSE to be addressed in the new GP contracts, but I believe that the current issues with Shannondoc and the provision of services present some important issues that must form part of these deliberations. The people of west Clare have been very active recently in holding public meetings on this issue and they have discussed the issue across the length and breadth of the county. It would be important for the Minister and his officials to engage directly with these people, to navigate a mutually beneficial response to the situation in which they find themselves. On the one hand, we have the GP co-operative claiming that falling GP numbers was behind a decision to scale back services in east, west and north Clare while on the other hand, the HSE says there are two fewer doctors in the county over the past six years.

In terms of the issues in west Clare, it is becoming clear that a row over out of hours rostering is the main driver behind the recently announced changes to services in this part of the county. It is fair to say that this is not a funding issue. The funds have not been cut despite the fact the service to the public is being reduced. Out of hours rostering and the availability of GPs is an issue. When people cannot access these services out of hours they are more likely to head directly for the hospitals, to be on the safe side and to avoid wasting time. This puts pressure on our hospital system which will, inevitably, lead to the litigation and the issues we are discussing this evening. It is not enough to ensure that doctors have indemnified themselves against the failings of the health service. We should be looking comprehensively at the issues that lead to the levels of litigation and the levels of patient safety we discuss perennially.

Galway University Hospital operated the full capacity protocol 181 times up to November and in Limerick, it was 283 times. The cuts in Shannondoc are forcing the people of west Clare into these hospitals. We are not developing primary care; instead, we are simply overburdening an already overburdened system.

Shannondoc provides a really vital, urgent out of hours GP service the people of Clare cannot do without. This scaling back of Shannondoc services will only result in more people joining the queue in the already overstretched accident and emergency departments. It can have no impact other to ensure the accident and emergency departments, which are already stretched to capacity, are further stretched.

We are becoming a more litigious society, but the best way to combat this is investment and open disclosure, to take the burden off the individual. Individualising the issues caused by the systemic failure in the health service, by forcing each medical practitioner to account for himself or herself in regard to indemnity is not necessarily going to solve the problems. The problems are systemic. Sinn Féin has no difficulty in supporting the Bill but we do so by using our time to point out the fact that this will not change the issues that cause people to find themselves in a combative situation with the health service.

I echo the sentiment expressed by Deputy Kelleher on the manner in which the HSE and the Department of Health fight with their own patients and their own staff. As a union official, I have had occasion to represent nurses. We all know that nurses are at the coalface of our health service. I am all in favour of ensuring full accountability but it is astounding the amount of money that is put into fighting with staff and patients. It is beyond comprehension at times. We support the legislation but do not believe it is anything other than a tiny piece of a very large jigsaw.

Deputy Alan Kelly

I want to say a few words on the legislation. Many people in the State are surprised that we actually need this legislation. We have been a long time waiting for it as it has been in gestation an incredible amount of time. I noted the Minister of State's speech; his predecessor, Kathleen Lynch, gave a very similar speech.

Deputy Finian McGrath

I did not rob her script.

Deputy Alan Kelly

It was very similar altogether but we will not go there.

It is incredible this issue has not been dealt with previously. Many of us know cases that have arisen because the legislation and the indemnity have not been in place. The gap in the legislation has created a range of issues for the individuals or groups involved, which is unnecessary and unfair on them. The fact the indemnity was not there and they had no cover has caused a serious burden and pain for many people. The legislation will help people any time there is a mishap. We must point out to the public, so they do not get concerned, that those working in the public system are covered. This relates to private practice. The legislation will speed up claims, litigation and awards, and all the stress and pain these cause to people who, unfortunately, find themselves in the situation.

The changes brought about through amendments on Committee Stage in the Seanad are welcome, because there was some concern and confusion regarding setting the minimum levels of indemnity through the Medical Council. The fact it will work with the State Claims Agency is something that certainly improves the legislation and makes it more robust. I have some questions on this and the Minister of State might answer them when replying. He spoke about 58 medical specialties and sub-specialties. I presume there is a big chart of various specialties available where they all have different risks, from very low risk to extremely high risk for a very complex medical procedures, and this is understandable. Will the Minister of State outline to the House the process by which all these risks will be set for minimum indemnity, with regard to the complexity of being able to assess the most high-risk specialties versus the most low-risk specialties, to ensure we can have confidence, particularly in high-risk areas, that minimum levels will be met and people will be protected? Certain specialties involve only a small number of people. They must be satisfied the indemnity cover set for them is appropriate. How will disputes, people with grievances or issues in this regard be dealt with? It is not fully outlined.

Deputy Kelleher referred to the cost of insurance cover, which has shot up by an incredible 42% since 2014 to €220 million. The impact this has for those taking out insurance is considerable, with regard to the cost of their plans, the cover they have and the general costs in a number of areas. What plans do the Minister of State and the Department of Health have in this regard? This has been rapidly growing in recent years. Are there any plans to stop this totally running out of control? There may not be plans. Perhaps the Minister of State will tell us when replying what are his comprehensive plans to try to manage this in the coming years.

This is very important legislation and it is unfortunate it has taken this long to be brought forward. It will give confidence to the public with regard to private practitioners that they will be covered. It would have been a worthy legislation if it had been in the House previously.

I had not intended to go near the next matter, but my colleague, Deputy O'Reilly, raised it. She referred to something very close to my heart, namely, the risks associated with what is happening in Shannondoc in County Clare. It does not cover just County Clare but it also covers County Tipperary. I use the Shannondoc service, as do my children. What is happening in County Clare at present is an absolute disgrace. It will create contagion throughout the country with regard to other co-ops. The service drop issues in east Clare and west Clare are not the same and the Department of Health and the HSE need to get a grip on this. In east Clare the drop in the number of doctors from 12 to two does not warrant a decrease from 55 hours to eight hours of service. It is a disgrace. I live in the area and I dare say I am closer to it than all the Clare Deputies.

Deputy Finian McGrath

I know it well.

Deputy Alan Kelly

In fairness to the Minister of State, he is down there quite a bit. There is huge concern among the public. They feel they are at risk. Someone living in Mount Shannon or Scariff will not be able to get to a GP in time. There is a review of paramedic services in the midwest at present and there is more fear because of this. I have been given assurances in the House and in committee by the Minister, Deputy Harris, and by the HSE that the review will only be positive. I presume this will be the case, but if it is not there will be a serious problem.

There is huge risk in the area and people are concerned and upset about the fact they do not have a service like the one they had. The volume of out of hours service is not there. This brings me back to the new GP contract because this will have to be covered. People will simply end up going to Limerick. In some cases they will go to Shannondoc in Limerick, if they can find it, or they will end up in the accident and emergency department, and we all know the problems with that in Limerick. I do not need to spell them out to the House. The chief executive of University Hospital Limerick cannot perform miracles. There will be higher demand there as a result of this, and it will cause greater patient risk, as the Minister of State can appreciate. It is unacceptable.

Many of the GPs in the area are very good and not all are in agreement with the decrease in hours. Some of them opposed the decision. The GPs have a contract to do a certain amount of out of hours service and, particularly in the cell in the Killaloe area, many simply do not pull their weight. This will happen across other cells and other co-ops. The number of doctors in the Limerick area who do not practice out of hours is incredible. They have contracts and they are paid by the taxpayer. It is not acceptable. The public is not getting the service for which the taxpayer pays. This will become a real issue. It started in Clare and I understand there are issues in other parts of the country. I am open to correction, but I understand there are issues in Donegal and other areas.

I hope that at some point, the Department and the Minister will discuss this at their meetings. We need a new GP contract. We need a little bit of ingenuity in how we set it out. In some parts of the country, particularly in rural areas, we will need to have directly employed doctors because of the geographical and other issues. It is a real issue in the area and will continue to be so despite what others may think. Many members of the public are quite disgusted by what is happening with the doctors. It is causing such concern that I can see it being an issue that will grow throughout the country, including in the midwest. I call on the Minister and his Department to accelerate the new GP contract and the plan for services across these areas. The co-op model is breaking down so I hope the Minister will give this his close attention.

Acting Chairman (Deputy Bernard J. Durkan)

Deputies Michael Harty and Mattie McGrath are sharing time.

Deputy Michael Harty

At the outset I wish to declare that I am a registered general practitioner. When I started in general practice many years ago my medical indemnity insurance was £40 but now it is €14,000, which will give Members an idea of the increase over the years. It is essential that a general practitioner, or any doctor practising in a specialty, has medical indemnity insurance and, having always worked in the public system, I was not aware that it was not a requirement of the Medical Council that a doctor have evidence of medical indemnity insurance. It would be a very brave doctor who practised without it but it is only a factor in private practice because, in the public health service, a doctor would not get paid without insurance so he or she has a great incentive to have it.

Deputy Alan Kelly wondered what the costs of medical indemnity insurance were and how they were arrived at. There are three companies providing medical indemnity insurance: the Medical Protection Society, the Medical Defence Union and Medisec, which is an Irish organisation. Actuarial evidence is used to determine how medical indemnity insurance is set for each medical specialty. For a general practitioner the amount is lower, at €14,000, but for an obstetrician or an orthopaedic surgeon it can go up to €150,000 because of the much greater chance of being sued. We have, unfortunately, become a very litigious society and the number of cases against Irish doctors has reached almost the same level as those against American doctors. I do not say that people should not have redress if they are damaged or harmed but there has been a huge increase in litigation against doctors, hence the huge rise in medical indemnity insurance.

This Bill applies to doctors in private practice. It is very important that evidence be provided that one has insurance because it is important to a patient who is damaged that he or she has some financial redress to compensate for it. The medical profession is highly regulated and the Medical Council is a very powerful body with many doctors, myself included, trying to keep ourselves out of its clutches, if that is not too strong a way of putting it. It is a very strict body and there is a great incentive for doctors to have medical indemnity insurance and to practise in a proper and safe manner. The ethos of the profession is primum non nocere which means, "First, do no harm". Medical mishaps do happen, however. A medical mishap is not akin to negligence and we are processing a new system of voluntary open disclosure in which, if a medical mishap occurs, the patient or the relatives of that patient are informed in a timely manner. Many cases of medical negligence may easily be resolved by an admission that something happened, with an explanation and a commitment that systems will be put in place to prevent the error happening in the future. Many people are happy with an explanation of what went wrong. That is in no way admitting that one has been negligent but it involves an admission that an error has happened. This is very important for the medical profession and I hope the relevant legislation for it passes through the Houses in the not-too-distant future. We have already discussed it in the Joint Committee on Health and we will do so again next Thursday. Medical indemnity insurance is primarily there to protect the patient and to compensate for any error.

Shannondoc was brought up this evening, though it does not directly address the Bill. It is an out-of-hours general practitioner service for patients and is one of a number of co-operatives which are beginning to feel the medical manpower deficit. A huge problem is coming down the road in respect of medical manpower, particularly in the GP area. Some 33% of GPs are over the age of 55, which will mean 900 GPs will retire in the next ten years while the number of GPs who have qualified from medical schools and training schemes are not sufficient to replace them. Many of them look at the contracts in the Irish health system, which have applied over the past 44 years, and will not be taking them up. Many newly qualified GPs are working as locums but will not take up a contract and jobs are coming up for which there are no applicants. This is a huge problem that needs to be addressed on a number of levels. The GP contract needs to be a flexible contract which offers part-time work, job sharing and salaried positions which will attract GPs to work, maybe not for a lifetime but for three or five years in rural Ireland. Rural communities deserve a service as much as communities in urban areas and the new GP contract is key to solving the problems with Shannondoc and the many other co-operatives around Ireland which are suffering from the same problems. The main problem is a lack of GPs in rural Ireland. The number of GPs working in the mid-western health board may not have fallen but most of the GPs are migrating towards urban centres, leaving rural practices without a doctor and out-of-hours services struggling to meet the demand.

Another problem is that the gaps that have been left in rural general practice have been filled by locums from outside Ireland, such as from South Africa and Australia, and their conditions of employment have changed substantially in recent years with the application of VAT to their services and immigration laws. They are required to come and work here for 90 days and then leave for 30 days, before coming back for 90 days and having to leave yet again for 30 days. No locum is going to do that because he can go to any country in the western world and work in much better conditions. The fundamental problem is in attracting GPs to rural areas. To say that the GPs who are still standing, and working, in rural Ireland are not stepping up to the plate is quite erroneous. It has been determined that a rota of one in ten is the lowest safe rota for a GP. That involves a GP working six and a half weeks per year in overtime, out-of-hours work. When one considers that there are professionals who have gone on strike because they have been asked to work 33 hours extra a year, the fact that GPs are expected to work in excess of 6.5 weeks' overtime per year puts the problem in context. We are forcing our young GPs out of the country and what is happening in Shannondoc is going to happen right across the country. It is a national issue, not just a local one.

I commend this Bill to the House. It is essential and it has my support.

Deputy Mattie McGrath

I defer to Dr. Harty and his experience. I have some limited experience of dealing with GPs and of watching very harrowing cases where we have seen the HSE and its legal advisers drag families through the courts for years, sometimes decades, and have then admitted liability on the steps of a court. Huge awards have been paid and trauma and stress have been inflicted on families in situations which were totally outside their control and unfair. I welcome the Bill as an effort to deal with this. It has been harrowing to hear statements on the news of a loved one who has fought sometimes for ten or 15 years. It is serious. The State Claims Agency needs to be reformed. If there is clear knowledge and legal expertise that says something happened, without admitting total liability, it must settle these cases. There must be humanity. In many areas, the HSE lacks humanity and the human touch.

Deputy Harty compared the insurance costs and legal claims when he started to those today. There seems to be no holding back. The figures for 2014 and 2015 as well as the anticipated costs for 2016 were quoted. The money is phenomenal. One would need a computer to tally it. It has trebled between 2014 and 2016. I am involved in a community involvement scheme and the insurance has increased from €50 per participant to €150; it has trebled. Lo and behold, when we got a cheaper quote, the insurance company told us it would match it. It is nothing short of a racket. I have said it here before. The insurance industry is an extortionist racket and legalised robbery. It could not be called anything else. Insurance companies tell customers if they get a cheaper quote they will match it, but first they give a shocking quote to a voluntary group that cannot afford it.

We are trying to attract young GPs. We have lost our best and brightest. It takes a village to rear a child. A person who studies medicine has to work and study very hard. Many ordinary, middle-class people - the new poor, as I call them - do not get grants, and their families have to put them through college. Then we lose them all as they go abroad because of the abject, dire conditions in which they are expected to work in public hospitals.

Rural GPs suffer loneliness and lack of support. We fought it in Bansha for years. If there is no doctor, there is no village. Those in the larger practices have the support of colleagues and others if they get sick. It has been 40 years since the GP contract was updated. A group of doctors had to break away from the Irish Medical Organisation, IMO, because the IMO is a cosy cartel, as in so many other areas of health administration, including the Department and the HSE. It is completely out of control. There is no understanding, interest, passion or vision to look after the ordinary people, ensure we have GPs, put some bit of respect and manners on the insurance industry and ensure there is some bit of humanity regarding settling claims and not dragging people to the courts for years. Nobody is accountable, that is the problem.

In 1983, Mr. Paul Kelly, the boss of Console, employed himself as a GP. Where were the checks and balances on him? Did he have indemnity insurance? I would love to know. It is a pity he did not have it in a charitable organisation either. We can see gaping holes. This is where we are left. I recently saw a case on television in which a fitness to practice committee was examining a case in the west in which a consultant did not know the difference between an ankle and an elbow. There is some difference. A vet dealing with an animal that could not tell him or her where it had a pain would know, but this guy did not know the difference between the ankle and the elbow. I wonder who employed him and what insurance cover he got. How could someone like that be insured? He could not be insured. How did he get through the system? How was he employed in a hospital? There are question marks all the time and I am sure there are many more instances.

Notwithstanding the powerful work that goes on in our hospitals and in GP practices and that is being done by front-line nurses, it is the HSE we need legislation for. We need legislation to get rid of it, to stand it down. It has cannibalised itself and is totally dysfunctional and unable to react to any situation, because there is not a shred of accountability. When I put down a parliamentary question to the Minister, it is referred to the HSE for an answer. It is a joke. Two former Fianna Fáil taoisigh promised me they were going to disband the HSE, but it goes on and works away and it is not accountable or made adaptable.

Last weekend, I met a woman whose two daughters went to work as nurses in Australia. Representatives of the Bon Secours Hospital in Cork went to Australia to entice them to return to work in that hospital. They returned, yet we in Tipperary cannot get them. They travel from Tipperary to Cork every day and will not work in South Tipperary General Hospital because it is bedlam. This morning nurses would not attend at the hospital because they could not cope. Trolley numbers have increased 220% this November compared to last November. Think about the front-line staff. We have ward managers, floor managers, bed managers, linen managers, hygiene managers and food managers. We nearly have yard managers. We have everybody to manage but nobody to work. The lunatics are running the asylum. We see what is going on in Portlaoise hospital. Ordinary, dedicated, passionate people who have taken the hippocratic oath to work to cure people are not supported. They are hindered, blindfolded, restricted and blackguarded by senior management. Most the time, they do not even have blankets or pillows to lie on the trolleys. If we saw it on television happening in a Third World country we would have collections. We have had collections to send food out those unfortunate people, but we have it on our doorsteps. There is no explanation for it. It should not be happening.

I salute the GP practices for the work they do. It is a tough job. They have to make decisions after a ten, 15 or 20 minute consultation. I recently brought the Minister for Health, Deputy Harris, to two GP practices in Clonmel, the Mary Street Medical Centre and the Western House Medical Centre. They have fabulous experience there. They have six or seven doctors with 20 or 30 years of experience each, totalling hundreds of years of experience. They have made huge investments in diagnostic equipment and they have medical insurance, which costs them a fortune. The HSE has a two-year waiting list for a simple ultrasound diagnosis. However, because of bureaucracy, the HSE will not allow patients to be diagnosed in these GP clinics, which have links to colleges and people in university hospitals to read the X-rays and scans. Instead, they must send their patients to the accident and emergency departments to further overcrowd them, for fear they are not bad enough, and wait a minimum of six months. It could be done in these GP clinics for a fraction of the cost and it would take away the pressure from the accident and emergency departments. How can we get this through to the HSE? We write to, telephone and make other contact with the HSE. The Minister and I visited another clinic that had extensive diagnostic equipment, some of which I did not even understand. Although this clinic could do the same, it must send its patients to accident and emergency, where they go into a packed ward and wait hours or even days on trolleys before meeting a junior doctor. I mean no disrespect to the people working there. These junior doctors are much less experienced than the GPs and are tired from working 20 hours shifts. Although this is supposed to be outlawed, they are working 20 hour shifts and are going around like zombies, but are expected to make decisions. The diagnosis could have been done in the calm and relaxed atmosphere of the GP clinic. The GP clinics I deal with are very warm, friendly places. However, this would involve the loss of a little bit of the imperial control of certain management systems in the hospital. This is what it is all about: control and egotistical power trips for promotions.

When the consultants retire, which they are entitled to do, they contract their services out to the HSE for weeks, if not months, afterwards. It is a rotten, disgusting racket and it should be stopped.

The HSE should not stop this because it is not serving the public or the sick. It is self-serving and it is shameful.

We have a hospital in Cashel on which €18 million or €20 million was spent after it was closed. There is not a patient inside it notwithstanding the bedlam 15 miles down the road in Clonmel. We cannot put a patient in it, even though the Minister, Deputy Harris, visited recently at our request to see what was going on. It is state-of-the-art but it is office after office. There are suites of offices and what is being done in them could be done in any office in any part of the country. There are plenty of them so let hospitals be used to treat people. I have asked the Minister about it and I asked the Taoiseach about it last week. HIQA will not allow it to be used because there is no lift. We had a perfectly good bed lift which I was in twice as a patient. However, in the upgrade, the planner of which I would love to know, the bed lift was removed for fear we would put a patient into it and interfere with their grand, powerful headquarters with its colour-coded tiles, armchairs and wall-mounted paintings. "We could not have patients in here; this is for us", they say. There is something rotten in the state of Denmark and there is something rotten in the state of the HSE. It is totally dysfunctional and we cannot use the facility. HIQA says that because we have no lift, we could not evacuate in the event of a fire. HIQA is cited because we do not have this, that or the other. I have told the Minister to sell it to the Bon Secours. He should put it up for sale to some private company that would come in, work it as a hospital and treat people rather than to have it as an emporium-style headquarters for officialdom. It is beyond a joke. We had St. Luke's psychiatric hospital for years and it served the people. It was closed down and one third of it is now offices.

I support the Bill but we need a great deal more legislation. We have to look at a lot more than persecuting GPs. By all means, they have to have insurance but we need to keep control of insurers. Insurance companies are watching this tonight and rubbing their hands with glee because they see money and slot machines. We must support the GPs and ensure, of course, that they have insurance, but we also need to have insurance at reasonable prices.

Minister of State at the Department of Health (Deputy Finian McGrath)

I thank Deputies Kelleher, O'Reilly, Kelly, Harty and Mattie McGrath for their support for the legislation. I also thank the Deputies for putting forward ideas and setting out some of the problems we have in the health service. That is what this debate should always be about. I welcome their contributions on Second Stage of the Medical Practitioners (Amendment) Bill and the fact the Deputies have expressed their broad support. Medical practitioners work tirelessly to protect public health and the vast majority do not engage in medical practice without adequate indemnity cover. This legislation will reassure patients that doctors are practising with appropriate levels of medical indemnity insurance cover. It should serve to weed out the very few, and I emphasise that it is a very few, who do not do the right thing, that is, those who do not have adequate levels of cover.

Deputy Kelleher referred to the possibility of delay. I do not expect the State Claims Agency to delay the process of specifying minimum levels of indemnity as adequate resources are available to the agency for this purpose. Proposals for open disclosure legislation will undergo pre-legislative scrutiny this Thursday. I agree with Deputy Kelleher that the legislation should be progressed as a matter of priority as part of the suite of measures relating to tort-reform, specifically the civil liability (amendment) Bill, which will introduce periodic payment orders. The legislation will allow for staged payments to those who have suffered catastrophic injuries.

Deputy O'Reilly raised very important issues in regard to Shannondoc, litigation and the working conditions of nurses. She also made a very important point about the Government constantly speaking about the €14.6 billion in the health budget that we secured this year. It is very important that the positive things are recognised too. We have €20 million for the National Treatment Purchase Fund to tackle waiting lists and 10,000 medical cards for children with disabilities are also coming on stream. We have also seen a reduction in prescription charges for people over 70 and supports and services for school-leavers with disabilities. We also had the €5 million to kick-start the Healthy Ireland fund. Things are happening and the money is being rolled out. I accept the Deputy's point that there are major issues of reform and efficiency. We must constantly invest in health services which have been neglected for many years. That is something we are trying to do. The last budget was a step and hopefully we can develop it further.

Issues were raised about the 58 specialties on the Medical Council register. Insurers must currently assess the levels of risk to offer insurance indemnity. The State Claims Agency will consult with the indemnifiers and insurers. It will also examine court awards and consult with risk assessors to agree the minimum levels required. How we are managing the increasing cost of insurance for private practitioners is a legitimate question. The Government approved the establishment of the capped scheme in 2004 which means that practitioners must only purchase indemnity cover to a certain level or cap. Over the cap the State pays the balance. The capped scheme was introduced by the Department of Health in 2004 to provide limits or caps in respect of clinical indemnity cover that consultants are required to purchase in respect of their whole-time off-site private practice. Under the capped scheme, consultants purchase indemnity up to certain limits or caps and the State's clinical indemnity scheme covers any claims arising in excess of these caps. Without the capped scheme, subscription rates for consultants in whole-time private practice would have been greatly increased. On disputes and their resolution, the Medical Council will publish on its website the minimum levels required for the different classes of doctors in the 58 specialties. The State Claims Agency will have worked out the minimum levels based on extensive consultations with the relevant stakeholders.

A number of Deputies referred to the GP contract. The development of the new, modernised contract for general practice to address the changing role of doctors in delivering chronic care within the community and allow general practice to play its part in addressing the challenges that face the health service is a priority. I emphasise that. The Department of Health, the HSE and the IMO are currently engaged in a comprehensive review of the GMS and other publicly funded health sector contracts involving GPs. Engagements to date have seen the Department, the HSE and the IMO agree a number of service developments, including the introduction of the diabetes cycle of care for adults and other patients with type 2 diabetes and a support framework for rural GPs which has increased the number of qualifying GPs to over 300. We have also seen a revised list of special items of service under the contract to encourage the provision of more services in the primary care setting.

When we are talking about these issues, it is important to remember that the whole ethos of the Department of Health and the HSE is a strong patient safety culture to minimise risks. Over the next two days, the Department will hold conferences on these issues and a strong patient safety culture will be top of the agenda. It is important to note that there will be no additional cost in the price of indemnity or insurance for medical practitioners as a result of the improved measures proposed in the Bill. The proposals will benefit patients should things go wrong with their medical care. It is important to reiterate that the Bill is one part of a wider package of other legislative proposals intended to benefit patients. Our focus must be on improving services for patients. Legislative proposals include the introduction of periodic payment orders for catastrophically injured people, pre-action protocols to streamline the legal process in medical negligence cases, the licensing of our public and private hospitals, the health information Bill and provisions for open disclosure. This wide range of legislative proposals is underpinned by the introduction of specific patient safety measures, including the establishment of the national patient safety office in the Department of Health and the national patient advisory council for patient safety. Patient safety is at the heart of everything we do in our health services.

Unfortunately, the reality is that providing health care is at times risky and under pressure mistakes sometimes happen. This Bill, together with all of the other measures I have mentioned, is a very significant step and is being actively progressed to ensure that the best possible care for patients is provided, even when things go wrong.

The Medical Council, which already does an excellent job as the regulator of the medical profession, will in the public interest create awareness among medical practitioners of the minimum levels of indemnity specified by the State Claims Agency. The Bill also gives the council power to sanction those who do not comply with the law.

This is a welcome Bill and I urge Deputies to support its passage. Once again, I thank all of the Deputies for their contributions to the Second Stage debate and look forward to further constructive examination of the Bill on Committee Stage. I commend the Bill to the House.

Question put and agreed to.