Joint Committee on Health debate -
Wednesday, 14 Dec 2022

Recruitment, Retention and Manpower Planning Issues: Irish College of General Practitioners

Chairman

The purpose of today's meeting is for the joint committee to consider issues with regard to the recruitment, retention and manpower planning for general practitioners. To enable the committee to consider this matter, I am pleased to welcome Dr. John Farrell, chair; Mr. Fintan Foy, chief executive officer and Dr. Diarmuid Quinlan, medical director, Irish College of General Practitioners.

All present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are again reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House campus.

I invite Dr. John Farrell to make the opening statement on behalf of the Irish College of General Practitioners.

Dr. John Farrell

I thank the committee for the invitation to appear before it today. The Irish College of General Practitioners, ICGP, is the professional body for general practice in Ireland. Our purpose is to encourage, foster and maintain the highest possible standards in general medical practice. Since its foundation in 1984, we have remained committed to the education and training of GPs, enhancing their skills, competencies and professionalism. The College is dedicated to GP education, training, research and advocacy on behalf of the profession and patients. The college supports GPs throughout their professional careers in the practice of evidence-based medicine to the highest standard. The college is the postgraduate training body, PGTB, responsible for delivery and governance of general practice training for the specialty of general practice as accredited by the Medical Council of Ireland. As of 30 September 2022, there are 4,257 GPs working in general practice. If those who may not be working in mainstream general practice here are excluded, this reduces the number to 4,187 GPs and equates to 2,807 full-time equivalents based on the number of clinical sessions recorded. There are 932 GP trainees working in general practice on a supervised basis who are undertaking the ICGP four-year national GP training programme. We anticipate that this number will increase to an annual intake of 350 by 2026. In July of this year, we accepted 258 new trainees, which is the largest intake in the history of the college.

We currently have approximately 2,807 full-time equivalent GPs working in Ireland. Our GP workforce is ageing, with 14% aged 65 years and over and with retirement plans accelerated by the Covid-19 pandemic. The Department of Health, the HSE and the Medical Council recommend increasing our GP workforce by 40%. We need to plan for a GP workforce of 6,000 by the end of 2028. We need substantially more GPs and, ideally, we need them now. GPs and their practice teams are pivotal to societal well-being. GPs provide comprehensive whole-person and continuity of care. The GP is the first point of contact in matters of personal health, cares for patients of all ages and disease categories and cares for patients over their lifetime. However, general practice is under serious strain. The HSE has a statutory obligation to provide GP care to patients with General Medical Services, GMS, eligibility. We cannot meet the current or future GP workforce or workload demands. We are not adequately resourced to meet current or future patients' clinical needs. GP practices are busier than ever, but less able to find replacements for retiring GPs or new GPs to expand their practices and deal with growing workloads. In our discussion paper on the workforce and workload crisis in general practice in Ireland, Shaping the Future, we outline six real-time practice profiles. They reinforce the challenges we are facing but also detail the great satisfaction of being a GP, whether in a large urban practice, a rural practice or a smaller practice. We are in the midst of a GP workforce and workload crisis that is getting worse. The Covid-19 pandemic has brought long-standing GP workforce and workload challenges to a head. This notwithstanding, the Covid-19 pandemic has also demonstrated that general practitioners are flexible, adaptable and eager to embrace change.

Addressing the GP workforce and workload crisis will require meaningful engagement of all stakeholders with sufficient resources and real-time data analytics. Working in partnership with the State agencies, we can deliver sustainable, timely access to high-quality GP care for all patients. We welcome the Minister’s decision to establish the strategic group on the future of general practice and we also welcome the opportunity have input in the terms of reference. This will ensure that the key stakeholders including the Government, the Health Service Executive, the Department of Health, the Irish College of General Practitioners, the Irish Medical Organisation, IMO, the Irish Medical Council, IMC, the Irish General Practice Nurses Educational Association, IGPNEA, and patient representatives can collectively address the challenges facing general practice to protect patient care. The ICGP is committed to working collaboratively and collectively to resolve the crisis that is impacting our ability to deliver timely patient care.

The Shaping the Future document is solutions-focused. This paper is based on our knowledge and understanding of our members and their patients within a healthcare system that is under significant continuing pressure. The GPs and GP nurses of Ireland perform 29 million consultations per year and we have a critical level of responsibility. We have listed ten potential solutions, providing an initial framework for the Minister’s task force. We are ready to lead to secure the future of general practice, which is pivotal to the health of our patients, the population and the wider healthcare ecosystem.

In summary, our proposed solutions include the recently-commenced non-EU rural GP initiative by the ICGP in collaboration with the HSE. This is a two-year programme to provide educational supports and clinical supervision to enable highly experienced non-EU GPs to work in rural Ireland. This programme will rapidly and sustainably augment our rural GP workforce. This initiative is an important rapid response to our severe GP workforce crisis. As this is the solution which will have the most immediate impact, we have moved on this with immediate effect. On Saturday, 26 November, the board of the ICGP approved the full implementation of this programme. Full details of this programme can be found in our attached documentation.

Another solution is GP-led multidisciplinary teams. We need to rapidly expand multidisciplinary primary care teams with nurses, pharmacists, phlebotomists, healthcare assistants etc., within general practice. The ICGP is currently working with our national universities to develop education programmes for phlebotomists, healthcare assistants and GP nurses. This will rapidly augment the GP team, delivering the optimal skill mix, enabling every healthcare professional to work at the top of their licence. This initiative requires additional resources to train and deploy these clinical staff. The HSE is developing the enhanced community care initiative. This will incrementally support GPs and our patients in timely access to clinical expertise, diagnostics and therapies. It is important that expansion in both areas is conducted simultaneously.

The current cohort of approximately 2,000 general practice nurses, GPNs, needs to be doubled. We need substantially more general practice nurses with resourcing and supports comparable to secondary care nurses. The ICGP and our colleagues in the Irish General Practice Nurses Educational Association have recently initiated engagement with our universities to deliver high-quality education to train substantially more general practice nurses. Given modest resources, we will commence and deliver this GP training of nurses early in 2023. The relevant statutory bodies need to provide the resources to support the future blended career expectations of our doctors. We need to take a realistic approach to the future career expectations of our young trainees and GPs and provide supports to ensure GPs have the option to undertake these blended careers, combining clinical work, research and medical education.

Suitable premises need to be provided for GPs and their teams. Most GP practices now require a larger brick-and-mortar footprint to house the expanded clinical team. Imaginative arrangements with leases and ownership need to be explored and delivered. Increased use of remote consulting by patients’ GPs should be explored. However, we need to ensure that strict guidelines governing video and telemedicine, along with monitoring of outcomes to ensure its suitability for various patient groups, are in place.

GPs need to be incentivised to set up in rural Ireland. Rural general practice needs sustained and urgent supports to survive and many rural GP practices are closing or closed. This will have an immediate and sustained adverse impact on rural communities and the broader healthcare ecosystem. General practice must include a career pipeline with a specific rural focus. The ICGP is considering the creation of a faculty of rural general practice, which will support rural GPs and highlight the many challenges facing rural communities and rural general practice.

The role of the practice manager needs to be further developed and supported. This will liberate GP time, enabling GPs to focus on clinical care and to spend less time on the business aspects of general practice. GPs need to spend less time on administrative work and more time on clinical work, including non-patient-facing clinical activity.

Just 9% of our intern doctors select GP training as their career choice. This fails to reflect a key strategic need. Ireland needs half of our medical graduates to specialise in general practice. This leaves our long-term medical workforce planning in a vulnerable position. To encourage more graduates to enter the speciality of general practice, medical schools need to immediately and significantly increase undergraduate clinical teaching in general practice. This will require appropriate resourcing of medical schools. We need to develop a new national funding model to support and secure medical student placements in general practice, which is essential to the GP workforce pipeline. It is the critical first step in this pipeline. The current system compels medical schools to separately fund GP placements, from their own internal budgets. This model simply cannot support the substantial expansion of undergraduate GP placements to sustainably deliver our future GP workforce. We need to adopt similar strategies to comparable countries such as Scotland, Australia, and Canada. We need to support and resource our medical schools to deliver clinical teaching in general practice. This is key to supporting medical student selection of general practice as a career.

Sustained investment is required to harness and deploy GP data-informatics to ensure a responsive, effective, and innovative service. Data is driving modern health services, informing, supporting, and driving policy and practice. General practice is a data-rich environment.

Irish general practice is changing rapidly and has changed beyond recognition in the last two years. General practice has also shown how flexible and adaptable it is to meet urgent needs. There are, however, huge pressures on existing GP practices, and general practice must be supported and resourced to retain existing doctors and recruit new GPs into practice. At present, general practice is working efficiently, flexibly in a patient-centered way, based in the heart of the community. However, general practice is at breaking point.

The next decade will bring enormous change. All parties must now come together and act to protect and grow general practice in the interest of patient care. We must act now to protect our patients and to retain high quality clinical care within the community. We need our Government and key stakeholders to respond decisively. In summary, this is not about GPs, it is about patient care and delivering timely patient care under a system that is under huge pressure and needs change.

Senator Seán Kyne

I welcome Drs. Farrell and Quinlan and Mr. Foy. How fit for purpose is the points system for patients and doctors? Is there a better way to do this? Would the witnesses recommend changes?

Dr. Diarmuid Quinlan

If we look at the medical student side, fewer than 9% of our interns select general practice. International evidence shows very clearly that if we want GPs to work outside the main cities then we need to select people from those areas and in their medical training ensure that a lot of their training is delivered in general practice. Ulster University has the newest medical school in the country and it delivers 30% of its undergraduate training in general practice. In week 1, year 1 in Ulster University, the medical students spend time in general practice. That is not replicated here. It means that our medical students are not exposed to general practice. Ideally, we would have a situation where our universities were adequately resourced to deliver a substantial amount of our medical undergraduate training in general practice. That will increase the number of Irish doctors who choose to work and stay in Irish general practice. We need to look at our medical education systems from the very outset. Looking at the medical students, we need a lot of the training to be delivered in general practice.

Deputy Seán Kyne

Are there people who would make excellent doctors who cannot get through the first step of qualifying for medical school?

Mr. Fintan Foy

That is a bigger issue. It is not something that we have given much thought to. Our emphasis is on those who are in medical school and ensuring they have the opportunity to spend as much time as possible in general practice. They would then feed through into the intern system and the training programme. That is our emphasis.

Deputy Seán Kyne

If there is a shortage of doctors, not just GPs, nationally and internationally, could greater capacity be brought through the system?

Mr. Fintan Foy

Undoubtedly, yes.

Dr. Diarmuid Quinlan

We train among the highest numbers of doctors in this country, per head of population, in Europe, and yet we do not enable a lot of them to remain in our country. We have a big shortage of intern places. If we want more doctors, then a very easy win would be to increase the number of intern places. We force many doctors who are not EU graduates to leave our medical schools and go abroad for their internships. I am thinking particularly of Canadian medical students who train here and then many of them are unable to secure an intern place. As a result, they go back overseas. Then a year or two later we are scouring the globe, looking for doctors, having forced our graduates to emigrate.

Deputy Seán Kyne

Why are they unable to get intern places?

Dr. Diarmuid Quinlan

Because we need more intern places. We do not have enough places. We need more intern places in general practice.

Deputy Seán Kyne

Is that just a matter of a financial package or incentivising the existing practices to take on interns? Is there an appetite for this in existing practices?

Dr. Diarmuid Quinlan

There is an appetite for expanding the number of interns in general and also in general practice.

Deputy Seán Kyne

Is a financial package needed, therefore, to ensure that this happens?

Dr. Diarmuid Quinlan

We need to create more intern places. There simply are not enough intern places. We did it during the pandemic but afterwards we cut back the numbers again. It is feasible to deliver more intern places.

Deputy Seán Kyne

That makes perfect sense if there is a support package within the Department to provide more intern places. Dr. Farrell mentioned the consideration of the creation of a faculty of rural general practice that would support rural GPs. What are the challenges regarding rural versus urban? Does a rural GP practice mean more house calls and more travel?

Dr. John Farrell

At the moment, according to HSE figures, approximately 30 communities around the country are without GP services or GP services are being provided by locums at huge cost. We need to encourage more people to practice in rural Ireland. That will need incentivisation. From an educational point of view, we are looking to establish a faculty of rural practice to encourage more people to practice in rural Ireland. This is badly needed. Rural and inner city general practice are the areas that have been, statistically, under-resourced.

Deputy Seán Kyne

We have a smaller number of people interested in becoming GPs at 9% and then the majority of those are more interested in larger, urban practices. Is that because they view that there is not a living to be made in rural Ireland?

Mr. Fintan Foy

It is just the nature of the practice. Generally for GPs, it is more attractive to work in a larger practice with all the supports that are available. Rural general practice tends to be more single-handed and there is a need to build an infrastructure around those single-handed GPs to enable them to practice and support their patients appropriately. They need to be incentivised to work in rural Ireland, as happens in Australia and other parts of the world. As a college, we want to help and provide an educational package to ensure that we can push more GPs into rural Ireland.

Dr. Diarmuid Quinlan

The crisis is particularly acute in rural Ireland. The number of GPs in places such as Skibbereen, Lisdoonvarna, Caherciveen, Achill Island is simply not sufficient to look after the patients. This is about patient care. In the areas I mentioned, the crisis is particularly acute. Those areas need more GPs. For a person living in Lisdoonvarna, for example, there is not a university teaching hospital ten or 15 minutes' drive away. We need resources to specifically support rural general practice

Deputy Seán Kyne

The Minister has flagged supports for Ukrainian doctors who have come here. Have the witnesses been involved in the design of that programme?

Mr. Fintan Foy

Not directly but we actually have a Ukrainian GP who is our lead for GPs in supporting Ukrainian people who are coming across. The Minister has put together a package which will help them to do the English language assessments and so on that are required by the Medical Council. That is very welcome

Deputy Seán Kyne

The HSE has focused on the building of primary care centres. Some of them have been successful and others have not regarding buy-in from GPs. Is there a necessity to ensure that buy-in before plans are designed, rather than building a facility and then hoping the doctors move in?

Dr. John Farrell

My practice moved into a primary care centre at the start of the pandemic. It was the best move we ever made. Apart from the GP practice, we have access to public health nurses across the corridor and speech and language therapy, and physiotherapy are upstairs. It is the way forward but it is not possible to have a large primary care building in every small town in Ireland. However, it makes sense to centralise activity within one building and it has worked well in the areas where it has been established. It is not for everyone. Not everyone wants to work in a large group practice.

Senator Seán Kyne

Is having a one-stop shop the way forward in providing better care?

Dr. John Farrell

It is certainly good from the point of view of patient care that people can access healthcare, provided it is local. One of the great advantages of general practice over the years has been providing quality patient care in the community. Many communities are not large enough to sustain a large primary care centre, but I am sure they can be built to scale.

Dr. Diarmuid Quinlan

For many of our younger doctors or graduates, the financial risk associated with buying or renting property in urban areas where the costs are high is a barrier and disincentive so many doctors would welcome primary care facilities.

Deputy Seán Kyne

In some of the smaller communities in rural Ireland, the population is decreasing and rural practices are less viable. Is there scope for having shared practices or for a doctor serving a number of small communities and not being in the same place every day?

Dr. Diarmuid Quinlan

There is a good example of that in west Clare. Professor Liam Glynn and his colleagues in that area are single-handed practices but they collaborate and work closely together to share resources and support patients in a meaningful fashion. That model has traction in parts of the country.

Deputy Seán Kyne

In my area, west of Galway city, there is a difficulty with the expansion of the out-of-hours services, Westdoc, as city-based GPs are reluctant to serve the more rural areas. Travelling up country roads in weather like we have today is a concern. Is there any solution to that problem as it seems to be a difficulty?

Dr. John Farrell

The problem is if we do not have a functioning primary care system - this is important - there is a knock-on effect on every other aspect of the health service. The number of beds on corridors gets the headlines but that is, in part, due to not having a functioning primary care system as people seek healthcare out of hours, which puts pressure on the out-of-hours system. If people are not seen promptly, they present themselves to emergency departments that are then flooded with patients and some people are admitted who may be more appropriately dealt with in the community. There is a knock-on effect all the time. It has been shown all over the world that a functioning primary care system significantly reduces pressure on out-of-hours services, emergency departments and secondary care. At the moment, while we have a functioning primary care system, we do not have the number of GPs we should have to provide the level of patient care that is necessary. People are now waiting weeks. We used to pride ourselves on a same-day GP service. The advent of chronic disease management is welcome and is providing quality care to our elderly population, but the chronic disease management programme means there are not enough routine appointments left on a day-to-day basis. We have to manage diseases such as respiratory syncytial virus, RSV, the concerns people have about strep A and Covid-19, which is still alive in the community and all those people have to be seen and, therefore, appointments for routine care are taking days or even weeks in busier practices. That is not acceptable. That is not what general practice is about but it is what is happening due to a lack of manpower. This has happened in a relatively short time. That is unfortunate.

Deputy David Cullinane

Dr. Farrell's opening statement sets out the challenges we have in this area, which are quite sobering. We all know people are waiting longer. As he said, the anecdotal evidence from people we deal with is that people are waiting longer to see a GP. A wait time of a day or three days for an appointment has become weeks in some areas, though not in all areas. It is becoming more common. Out-of-hours GP services are quite patchy and are non-existent in some areas. It is a challenge.

I will first touch on the figures because they are important to understand what capacity is needed. We need to understand the problem, the scale of the challenge and the solutions ahead of us. There are 2,807 GPs working in Ireland and 14% of those are aged over 65. Do the witnesses have any projection of how many of the 2,807 GPs it is anticipated will retire in the next five years?

Dr. Diarmuid Quinlan

It has come in at a headcount of approximately 700. I will give the example of Skibbereen, which had ten GPs at the start of this year but is now down to seven due to retirements for various reasons.

Deputy David Cullinane

Is the 700 over a five-year period?

Dr. Diarmuid Quinlan

It is within the next three years.

Deputy David Cullinane

If 700 of the 2,807 GPs retire in the next three years, that brings us down to 2,100.

Dr. Diarmuid Quinlan

That is not whole=time equivalents. It is perhaps 500 whole-time equivalents.

Deputy David Cullinane

Okay, 500 is still significant. How will we get to 6,000 by 2028? We need 4,000 additional GPs. In reality - we need to be straight - do we have any chance of reaching or getting anywhere near the target of 6,000 on current training models and funding?

Mr. Fintan Foy

No, realistically we do not by 2028.

Deputy David Cullinane

Yet we need 6,000. How did we end up in a situation where we need 6,000 GPs and yet we have no plan of substance to get anywhere near 6,000? What is the witnesses' best estimate for what we could achieve by 2028?

Mr. Fintan Foy

Based on the numbers that we are taking into training, which will be close to 350 by 2026, and the establishment of the non-EU programme, best estimates are between 4,000 and 4,500.

Deputy David Cullinane

Does that include retirements?

Mr. Fintan Foy

Yes.

Deputy David Cullinane

Mr. Foy thinks we could reach 4,500 by 2028.

Mr. Fintan Foy

I hope so. That is based on being successful in retaining everyone we train.

Deputy David Cullinane

My problem is that a health service cannot be built on hope. It does not work. There must be real targets with funding behind them and certainty we can do it. Many of these targets are unachievable, there is no plan on how to get there and the numbers are being put out that we hope to get to. No one can give me a guarantee that the ICGP will reach 4,500 by 2028.

Mr. Fintan Foy

There is no guarantee. We discussed earlier that we need to put a ten year strategy in place for general practice, with proper targets we can achieve over that period.

Deputy David Cullinane

We also need to double the number of general practice nurses-----

Mr. Fintan Foy

Yes

Deputy David Cullinane

-----over the same period, by 2028. Is that correct?

Dr. Diarmuid Quinlan

I agree with everything the Deputy said. We will not have a sufficient number of GPs. As an interim solution we need to look at other healthcare professionals. We need to substantially increase the number of general practice nurses. They are a phenomenal resource.

Deputy David Cullinane

I will stop Dr. Quinlan there. The official training body, the ICGP is telling me we do not have enough GPs and by 2028 we still will not have enough GPs.

Dr. Diarmuid Quinlan

It will be challenging.

Deputy David Cullinane

Dr. Quinlan just said that by the ICGP's own measurement, even by 2028, looking five years down the road, we will still not have enough GPs.

Dr. Diarmuid Quinlan

There is a global shortage of GPs and we are simply reflecting that global shortage.

Deputy David Cullinane

We are dealing with this State, which has a particular challenge. That makes for sobering reading. I will build on that. We are at a point where we have 2,807 full time equivalent GPs.

Maybe about 700 are going to retire, 500 of whom are whole-time equivalents. We have to get to 6,000 by 2028 if we want to provide the best general practice service we can provide. By April of this year, 400,000 new patients are going to receive their GP-only card. That is the Government proposal, is it not, that by April of next year, half of the population will be covered by free GP care?

Dr. John Farrell

Yes, there are plans to put in place increased GP, or doctor visit, cards.

Deputy David Cullinane

That is what I am saying. In the budget this year there was a big announcement of an additional 300,000 patients or more, plus the six-years-olds and seven-year-olds. A figure close to 400,000 new patients will have GP-only cards. Is that not correct?

Dr. John Farrell

That is our understanding. I do not have a timeline on it.

Deputy David Cullinane

The Minister outlined the timeframe. In the budget he said it was April of next year and that there would be engagement with the Irish College of General Practitioners and other representative bodies, including the Irish Medical Organisation, IMO, to reach the point where this would be in place by April of next year. Is the system ready for that, from the perspective of the Irish College of General Practitioners?

Mr. Fintan Foy

From our perspective, no, it is not ready. As my colleagues have outlined, the system is already under extreme pressure. While we welcome this initiative and fully support it in the context of Sláintecare, the idea that the system would be able to cope with it by April is very challenging.

Deputy David Cullinane

What would be the consequences of doing it? From the witnesses' perspective, if on April 1 next year, 400,000 get a new GP card as the Minister wants, what will happen in the short to medium term, for example?

Dr. Diarmuid Quinlan

We have good statistics that indicate that will require an additional 640,000 GP consultations per year, or about 120 whole-time equivalent GPs. With our existing workforce constraints, putting additional pressure on that system will clearly mean people who need to be seen on the day will find it increasingly difficult to get seen in a reasonable timeframe.

Deputy David Cullinane

What does that mean in practice? We need to be straight about we are facing into. Like everybody else, I want to see more people covered with GP cards, but we also need to put the infrastructure in place. We need more training and funding. We need to train more GPs. We need to have a new contract that reflects a modern GP practice. I accept all of that, but the clock is now ticking. We are going to reach April in a very short time. If the Minister is right, these cards are going to be issued. At least, that is his intention. If that happens, in the view of the Irish College of General Practitioners, what will that mean in the short term and the medium term? I do not mean that people may be waiting a bit longer. What will that mean in terms of pressures on the system given what I have just been told?

Dr. John Farrell

It will potentially mean increased waiting times for people waiting to be seen. Routine appointments will go out further. People will be waiting longer for things like contraceptive services, cardiac services, blood pressure checks etc. There is not a practice to my knowledge that would refuse to see anybody in any emergency or immediate situation. That is putting more pressure on GPs and GP nurses. That is happening. People are sick and they are being seen.

Deputy David Cullinane

Is Dr. Farrell saying the immediate consequence of doing it too quickly , as he sees it, is that the wait times for GP appointments will increase?

Dr. John Farrell

If these cards are introduced, there is increased demand on the system, and we do not have the personnel to provide the service, then the natural outcome from that is there will be increased waiting times to see a GP.

Deputy David Cullinane

What engagement was there with the Irish College of General Practitioners, ICGP, before the budget announcement that there would be an additional 300,000 cards, or 400,000 if we include the six- and seven-year-olds? In terms of scale, that is obviously a lot of people. What level of engagement was there before that announcement?

Mr. Fintan Foy

In the context of the roll-out of the GP cards, that negotiation or engagement would be with the IMO rather than with the ICGP.

Deputy David Cullinane

I know, but the latter provides the training and projections of capacity. What level of engagement was there?

Dr. John Farrell

In that context there was no engagement.

Deputy David Cullinane

None. It is the job of the ICGP to make sure we have enough capacity, that we are looking to the future to know what capacity exists, and to know the projections in terms of changing demand and demographics. Is that not essentially what it does? Does it also provide the training?

Mr. Fintan Foy

That is our role, yes.

Deputy David Cullinane

It is the training body, and yet there was no engagement whatsoever with it about doing something very substantial, which is the issuing of 400,000 new cards. It was not asked what impact that would have on the system.

Mr. Fintan Foy

No.

Deputy David Cullinane

No. Was that a mistake?

Mr. Fintan Foy

All the negotiations would have been-----

Deputy David Cullinane

I am not talking about negotiations. That happens with the IMO. I am talking about the capacity to deliver something big. Was it a mistake not to have engaged with the ICGP?

Mr. Fintan Foy

I suppose, yes, we would have liked to have had some contact in that respect. I think there is very good engagement around the growth in trainee numbers and aligning that. Our intention, as we have said, is to have 350 trainees. There has been very good engagement in that context over the past couple of years.

Deputy David Cullinane

Have the witnesses been told this is going to kick in next April? When is it going to kick in? Is there some indicative timeframe? Have they been given any direction of travel as to what is going to happen?

Mr. Fintan Foy

Not directly to us, no.

Deputy David Cullinane

Not directly. That is extraordinary. We have a big announcement. I support the roll out of more GP cards. Obviously, we all want to see it. However, we need to get the foundations right. That there was no engagement with the training body that provides the capacity when we are trying to roll out something so ambitious was a big failure on the Department's side and the Minister's side. I just want to note that.

Deputy Róisín Shortall

I welcome the witnesses and thank them for their presentation. It strikes me there is quite a serious mismatch between the professional body and the representative union for GPs. They are very often not on the same page on key issues, particularly the contract and the model of care. I have long been of the view that the GP contract is not fit for purpose. It is a 40-year-old contract, and while there were some amendments to it last year, it is very outdated. We know from various pieces of research that have been done over the years that younger GPs do not want to work in single-handed practices. We know they want to work as part of a multidisciplinary team. They do not want to be forced into a situation where they have to become business people and set up their own premises. The contract does not support that unless somebody has capital behind them. The model of care desperately needs to be updated. It does not provide for the multidisciplinary team approach. It does not provide for a greater role for practice nurses or advanced nurse practitioners. That skill mix needs to be updated. It is very difficult when the professional body is proposing one thing and the union seems to be holding back some of the modernisation required. Premises especially are a huge issue for newly graduating GPs. It is certainly my experience, from talking to many of them over the years, that they are not in a position to set up their own practice, nor do they want to do that, because they do not believe that is best practice. However, when it comes to the State providing primary care centres, there is huge opposition. That is why I am saying there is a complete mismatch between the objective of having GPs in multidisciplinary teams and there being resistance to allowing that model.

Dr. John Farrell

We have worked very closely with the IMO, particularly over the past two years during Covid. Our role in this is as the education body, for people who want to pursue a career in general practice and the education around that. That is our job. That is what we do. We realised when we put forward this Shaping the Future document that we could not do this on our own. That is why we asked for, and included in the document that we needed, the input of the IMO. We are not the experts on that . We are not in charge of looking at the contract. We are in charge of education, training and the continuing professional development of our members. This came from the board of the ICGP. We realised at the very start this had to be a discussion document. It was not a proposal. Coming in front of this committee today, we were hoping we would have its support for putting forward that the Minister's strategic review would take place quickly, because there are major problems, and that there would be a time limit put on that.

All the people mentioned such as the IMO and the HSE would be involved with that. There would be an executive-type group that would come forward with practical solutions to what is clearly a huge problem. I go back to the point I made earlier that this is not about GPs and GP services. This is about patient care.

Deputy Róisín Shortall

Absolutely, and we all have better patient services and patient healthcare in mind and that is the objective for us all. The difficulty is that this is essentially a workforce planning issue, and we have been talking a lot about inadequate workforce planning in the Department. Dr. Farrell has set out a number of steps that should be taken and I cannot help but ask why this is not being done. Why were those steps not taken years ago? This has been a looming crisis for at least the past ten or 15 years. What engagement has Dr. Farrell's organisation had with the Department and what does it take to move this stuff on? There are ten proposals and those, and other proposals, need to be activated now and operationalised. However, it seems we continue to talk about them. What is happening at departmental level?

Dr. John Farrell

It takes engagement like this to act as a lever to start the conversation about things that need to be done. We need more GPs and we need more GPs to be trained. We have agreed that is an issue. Deputy Cullinane has clearly said that the targets we hope for are unlikely to be reached, but if we do not start with some sort of solution-based discussion, we will not get anywhere and Deputy Shortall will be having this conversation in three or four years' time with somebody else sitting here. We hope from this committee today that people like Deputy Shortall who have a huge interest in health would actually say these are reasonable suggestions. They are proposals. Other people will have to look at finance and contracts and the IMO will have-----

Deputy Róisín Shortall

Sure, and I am sure this committee will do everything we possibly can because we are acutely aware of the logjams within the health service, especially in relation to GP services. GPs are at the start of the process, if you like, and unless we get that right, it will cause difficulties upstream. We fully understand that. I am wondering what kind of engagement Dr. Farrell's organisation has had at a senior level within the Department in terms of these very important issues.

Mr. Fintan Foy

I will make a couple of points on that. We are aware the Minister has welcomed the report, and one of our colleagues had a meeting with the Minister earlier this week. We were also invited to input into the terms of reference of the strategic review, and I think that was as a result of the output of this report. There is that level of engagement and we would be very encouraged by that. To go back to the point regarding our relationship with the IMO, we have a very good working relationship with it and would engage with it regularly. The success of the roll-out of the chronic disease management programme, which was a very strong engagement between the IMO, which negotiated it, and the delivery of the educational aspects from the ICGP, is an indication of that relationship.

Deputy Róisín Shortall

I am not denying that I am just saying that sometimes-----

Mr. Fintan Foy

We will never see eye to eye on everything.

Deputy Róisín Shortall

-----there seems to be a mismatch. One of the things that is being proposed is increasing the number of training places. What does it take to do that?

Mr. Fintan Foy

There is a programme in place and this year we took in 258 trainees into our programme, and the intention is to ramp that up to 350 by 2026.

Deputy Róisín Shortall

What needs to happen for that increase?

Mr. Fintan Foy

Our trainees spend two years in hospital-based posts and two years in general practices. The rate-limiting factor is the availability of hospital training posts, particularly around some of the specialties such as paediatrics. To give credit where it is due, there is strong engagement between ourselves and the HSE on that to identify those posts. What stops further expansion is the availability of hospital posts. Also, it is that-----

Deputy Róisín Shortall

Just to get down to the root of that, what needs to happen to increase the number of hospital posts?

Mr. Fintan Foy

That they are recognised for training purposes. There are a number of posts that are not recognised specifically for training purposes, so there is a need for those posts to be recognised specifically for training purposes.

Deputy Róisín Shortall

Why is that the case?

Mr. Fintan Foy

A post has to be properly structured to enable a person to go into it for training purposes.

Deputy Róisín Shortall

What does it take to create those properly structured posts?

Mr. Fintan Foy

That would be engagement between the hospitals and the HSE and training bodies like us to make sure those posts are appropriate.

Deputy Róisín Shortall

Is there resistance to that?

Mr. Fintan Foy

No, I do not think there is resistance. Within a hospital system, the emphasis is on providing immediate care and having people in post, whereas if there are trainees moving through the system, that is an added burden. The long-term benefit, however, is such that it is better to have trainees in post than non-trainees in post.

Deputy Róisín Shortall

Is that a resources issue-----

Mr. Fintan Foy

It is a resource issue.

Deputy Róisín Shortall

-----or is it an organisational issue?

Mr. Fintan Foy

It would be a combination of both resources and organisational.

Deputy Róisín Shortall

Where do the resources need to be put? What is the resource demand in that?

Mr. Fintan Foy

There would need to be more supports in place for a trainee than would be needed for a non-consultant hospital doctor, NCHD.

Deputy Róisín Shortall

Such as more staff?

Mr. Fintan Foy

More staff. Yes.

Deputy Róisín Shortall

So is that a catch-22?

Mr. Fintan Foy

Yes, it is.

Deputy Róisín Shortall

Is it because there are a high level of vacancies at consultant level?

Mr. Fintan Foy

Yes, consultants would be needed in post.

Deputy Róisín Shortall

Okay. The new contract, hopefully-----

Mr. Fintan Foy

Hopefully.

Deputy Róisín Shortall

-----will help the situation.

Mr. Fintan Foy

We have seen great progress in that over the past 15 months.

Deputy Róisín Shortall

I want to raise one other issue and that is the weakness of the out-of-hours cover that is being provided. It seems to be more designed to comply with an outdated contract rather than actually providing alternative pathways for people to the emergency departments, EDs. A parent with a young child has very few options in terms of where they can access care out of hours. Is there potential for employing GPs to provide out-of-hours services, especially as a lot of female GPs, for example, would like the flexibility of that? Have the witnesses looked at the possibility of employing people to work part-time or out of hours?

Dr. Diarmuid Quinlan

I was working in SouthDoc in Cork last Saturday and it is a really busy service. It is staffed primarily by the GPs of Cork and Kerry during the daylight hours and the overnight service is staffed by employee doctors who undertake the role Deputy Shortall suggests. It comes back to the shortage of GPs. The GPs have a choice whether to work in daytime general practice or to do largely out-of-hours, and out-of-hours work brings its own challenges for doctors.

Deputy Róisín Shortall

It can suit some.

Dr. Diarmuid Quinlan

It can suit some, absolutely.

Deputy Róisín Shortall

When Dr. Quinlan says employed in SouthDoc, who are they employed by?

Dr. Diarmuid Quinlan

By SouthDoc.

Deputy Róisín Shortall

That is somewhat different from what I am talking about-----

Dr. Diarmuid Quinlan

They are employed.

Deputy Róisín Shortall

-----where they could be employed.

Dr. John Farrell

It goes back the same thing that there would not be the demand on the out-of-hours service because a lot of it now is spillover effect in that people are ringing late in the day to have a sick child seen to. It would reflect what is happening in all GP practices at the moment. Many people are leaving their appointment times free between 4.30 p.m. and 6 p.m., or whatever time out-of-hours takes over, to see those sick people, and there has been a huge number of sick children. If we had the capacity within the system, they could be seen and should properly be seen within daytime hours so they could then access prescriptions from pharmacists instead of all that-----

Deputy Róisín Shortall

Sure, but people do not necessarily get sick during daytime hours. I want to be clear that it is not a criticism of doctors, and I would not expect a doctor who is working a full week with all the onerous responsibilities in a practice to then do night-time hours. What I am asking is whether there is potential for increasing capacity by employing people? For example, the HSE would employ people to provide alternative services to EDs. Does Dr. Quinlan think there is potential for that?

Dr. Diarmuid Quinlan

In my practice we have eight GPs working, about five and a half whole-time equivalents. The workforce plan suggests we should have 40% more doctors, so we really should have an extra three to four doctors serving the same population. If we could do that, we could see everyone who is sick on the day and that would very substantially remove a lot of the burden from the GP out-of-hours, but because we simply cannot resource and recruit sufficient GPs for daytime work, it pushes a lot of work into GP out-of hours. I would see the solution for the principal part of it as having a very substantial uplift in the number of GPs available, so if your child is sick you can see your usual GP in normal daytime working hours. I absolutely agree with Deputy Shortall's comment that people do not get sick just between 9.00 a.m. and 5.00 p.m. Monday to Friday.

The GPs work the majority of sessions in out-of-hours services, so if there were many more daytime GPs, certainly in SouthDoc, it would substantially alleviate the challenges. To my mind, everything comes back to the very severe GP workforce crisis.

Deputy Róisín Shortall

I thank Dr. Quinlan.

Deputy Gino Kenny

I thank everyone for attending to discuss this issue. My first question relates to the first page of the written submission. It concerns the GPs in the State at the moment. It was said there are 4,257, with 2,807 full-time equivalents. What would the figure have been 20 years ago or, even better, 40 years ago?

Dr. John Farrell

Tragically, I was in practice 40 years ago, but I cannot remember the number. We have more people now but there has been an increase in the population. To my knowledge – I stand to be corrected on this – there has not been any great increase in the number of GPs holding GMS contracts over the past ten or 15 years. The number has been fairly steady, at around 2,500. There has not been an increase in the number of GPs practising in the country over the past ten or 15 years, for sure. While care has become more complex and the population has increased, these have not been matched with an increase in GP numbers.

Deputy Gino Kenny

It is recommended that the country should have 6,000 GPs. Dr. Farrell said there was a four-year course. To enter the course, what qualifications does a person have to have?

Dr. John Farrell

The students do their basic medical training. If it is at postgraduate level, that is for four years. If the students go through traditional medical school, it is for five years. Then they have a year's internship, after which they are fully qualified and fully registered with the Medical Council of Ireland. After that, they can enter a four-year GP training programme. From start to finish one is looking at either nine years or ten years to be sitting in a GP surgery as an independent practitioner.

Deputy Gino Kenny

Nine to ten years before-----

Dr. John Farrell

That implies somebody starting from the leaving certificate or somebody entering a postgraduate course. There are two routes of entry – traditional and postgraduate. People who have completed another degree are not expected-----

Deputy Gino Kenny

So it is in or around nine or ten years.

Dr. John Farrell

Yes, that is correct.

Deputy Gino Kenny

What does the four-year course involve? What are the criteria?

Dr. John Farrell

Two years are spent in hospital posts. Mr. Foy said we therefore need good co-operation from the hospitals. Students would normally do four- or six-month placements in the various specialties, and then they would have two years supervised in a GP setting, which obviously involves a completely different model of care from the one provided by hospitals. They get their basic training in hospitals in paediatrics, obstetrics, psychiatry, and accident and emergency medicine, and then they spend two years under the tutorship of an experienced GP trainer. We are responsible for the delivery of that training. We took that over from the HSE in October last year.

Deputy Gino Kenny

When GPs qualify, where do they gravitate towards? Obviously, there is rural–urban factor. Are they gravitating towards individual or collective practices?

Dr. John Farrell

From what we have seen in recent years, I believe many of our younger doctors tend to gravitate towards larger practices, where there might be a different skills mix. They can provide specialist care within that if they have a special interest. The tendency is to go to the larger group practices, which is one of the reasons there is a deficit of doctors in rural areas. Some practices are more attractive than others, and obviously there are many personal influences related to relationships and family determining where people might wish to practise.

Deputy Gino Kenny

With regard to the public and private sectors, towards where are doctors gravitating?

Dr. John Farrell

Most large general practices would have GMS contracts. Thanks to recent changes in legislation, those who qualify from our national training programme can actually apply to take up a list, but, as Deputy Shortall said, they are voting with their feet. They do not necessarily want to get involved in the business end of things. Finding a premises, especially in the larger urban areas, is an issue. The costs are huge when setting up a practice. People are more inclined to join others if possible.

Deputy Gino Kenny

That seems to be the general model.

Dr. John Farrell

Yes.

Deputy Gino Kenny

On the general practice nurses, Dr. Quinlan is saying there needs to be a doubling over the next period of time. He is saying the general nurse practitioner training course will be delivered. Has there been a high uptake?

Dr. Diarmuid Quinlan

GP nurses have a huge role in general practice. Most parents see that. They see their children getting vaccines and cervical smears and receiving chronic disease management. The nurses play a really important role. They are an integral part of our GP training programme for our GP workforce. However, we simply do not have anywhere near enough of them. I worked in the UK, where most practices the size of mine had five to eight general practice nurses working in them. Therefore, we need to increase very substantially the number of general practice nurses. We are working with some of the universities to deliver an education programme for nurses to facilitate their entry into general practice. With a modest resource, we anticipate that we could deliver a substantial cohort of new general practice nurses in 2023.

Deputy Gino Kenny

What is the route into general practice nursing?

Dr. Diarmuid Quinlan

Most will have already completed their basic nurse training and have a qualification. They are registered general nurses. Some select work in hospitals and others choose to work in general practice. General practice nursing is a specialty in its own right and entails a challenging, diverse workload. The nurses work really well in conjunction with their GP colleagues.

Deputy Gino Kenny

How long will the course for general practice nurses be?

Dr. Diarmuid Quinlan

It will probably be six months within the universities. That is the programme we envisage.

Deputy Gino Kenny

Six months. It is not that long.

Dr. Diarmuid Quinlan

But they are already qualified as nurses. We are building an additional package of skills specific to general practice.

Deputy Gino Kenny

What skill set would be provided in the six-month course?

Dr. Diarmuid Quinlan

It is a very broad course because general practice is very broad. It deals with subjects such as children, childhood vaccination, cervical smears and chronic diseases such as asthma, diabetes and chronic obstructive pulmonary disease. Our nurses are really excellent at managing stable chronic disease. Also covered are the care of older people and palliative care. The course will cover the whole spectrum.

Deputy Gino Kenny

Other Deputies and I have been contacted about the difficulties in gaining access to a GP, even in very urban areas. In the past year, I have received a fair few emails just about seeing a GP where I live, Dublin Mid-West. There are people who have contacted 15 or 20 practices but who have not been taken by them. This is a huge issue. I am not blaming the witnesses, obviously, because there is a shortage. People are going outside their own areas, and even constituencies, to try to find a GP. The shortage of GPs affects not only those in rural areas but also those in urban areas. GPs can take only so many in their practices.

Dr. Diarmuid Quinlan

The area of north Cork including the towns of Kanturk, Boherbue and Millstreet had 18 GPs in 2018 but that number is now down to 12. The population of the area has expanded because people are moving there since the housing is more affordable. Twelve GPs working in the area clearly cannot do the work that 18 GPs undertook previously.

Like many practices, they are simply saying they cannot accept new patients onto their list. Having said that, there is a huge shortage of GPs. In my practice, for example, we employ a phlebotomist who takes blood and that has freed up nursing time. By freeing up nursing time, the nurses now do some of the stable chronic disease management like diabetes care, asthma care and so on. That frees up GPs to take on more complex care. Increasingly, by expanding the multidisciplinary team, we ensure all the healthcare professionals are working at the top of their licence. While we need more GPs, we also need substantially more GP nurses, phlebotomists, healthcare assistants, and pharmacists in general practice.

Chairman

We will now move on to Deputy Durkan. Is he on the campus in Leinster House?

Deputy Bernard J. Durkan

I am; I never leave it. I welcome our guests. I have been listening to the discussion for its duration. I am a little concerned about one or two things, namely, forward planning in the provision of services in a country that has an increased population, which is still increasing. I listened to somebody making a presentation in the House last night about what pertained in 2011. Many people forget that there were half a million people unemployed in 2011. People were emigrating on a daily basis in their thousands to countries all over the world. Whatever prevailed in 2011 is no longer relevant but what is relevant is the rapidity with which people came back again. The demands have increased. The demand for housing has increased and the demands for medical services and education services have increased. My question is simple. What provision has been made for this in the context of the present discussion? Have we made submissions to the effect that we need X number of GPs? Incidentally, we are heading to a situation - well, we are there - where if the GP is not available the only other place to go is an accident and emergency department. That creates further problems for the accident and emergency department. My colleague, Deputy Shortall, said there is a lot of opposition to primary care centres. There may well be but we need to have some locations like that. We need to solve the accommodation requirements of GPs and bring together a number of GPs under the same heading, i.e., the primary care centre. If we cannot do that, we are going to have serious voids, not only now but for the foreseeable future, in the availability of GPs. This is a primary requirement. The health and safety issues immediately occur and we need to forward plan in such a way as to ensure we have at least the minimum requirements in place on time. How far are we going down that road? Have we gone down that road adequately to ensure the HSE or whoever is responsible is fully aware of what the circumstances are?

Dr. John Farrell

Deputy Cullinane said earlier that the figures we provided are sobering. There are some good initiatives in our proposals. We have this new non-EU proposal for rural practices. The news is not all bad. We have increased trainee numbers by 60% in the past five or six years, which is huge, and they are going to increase again. The Deputy is right. We need adequate planning. That is the purpose of this. We asked initially for a task force and the Minister has agreed to a strategic review. What we are looking for from this committee is to make sure that happens in a timely fashion so the matters the Deputy raised can be addressed and we can come up with practical solutions. All the members have identified issues in their own constituencies. We are all aware there is a serious issue with this. We were hoping the strategic review, with the committee's support, would take place quickly, that it would be time-limited and that we would get all the people around the table saying what are we going to do. It is about patient care and reducing pressure on the other services so we have a functioning primary care system. We agree with the Deputy that that is what we need. We need that level of planning now at this stage as a matter of urgency.

Deputy Bernard J. Durkan

The other point I want to make, which has already been referred to, relates to retiring GPs. It has been known for some time that these GPs are going to retire. My criticism in the past has been that, even though it was known they were going to retire, had to retire or preferred to retire, whatever the case may be, and were entitled to retire, no provision was made for a seamless handover or to encourage new people into the system in such a way as to ensure the general public could be reassured that adequate provision was being made.

The other point I am concerned about is this: several members have said it is very difficult to meet a GP, for all the reasons we talked about. I have said this before. I believe we are becoming the country of waiting lists. People have to get on a waiting list for almost everything. That should not be the case. We need to get the forward planning right. I am agreeing with Dr. Farrell there. We need to accelerate it. It is not enough to say it; we need to put it into operation in every case and in every health area. We need to do that and we need to do it quickly. The ground-level demand has to manifest itself straight away. We need the ministerial response, or the HSE response, or whatever is required to happen next, to quickly follow and put it into operation. A quick turnaround is what is needed.

Dr. Diarmuid Quinlan

I absolutely agree that we need a rapid response. In conjunction with the HSE, the ICGP has established a non-EU GP initiative. This is a short-term emergency response to substantially augment the number of GPs available, particularly across rural Ireland. It has already commenced. We have 18 GP candidates who are either in post or are starting in posts in the next few weeks. We have a substantial pipeline of other non-EU GPs and we are supporting these doctors with a two-year programme of education supports, protected study leave and close clinical supervision by a named GP in a practice, at the end of which they will be able to sit the MICGP professional exam. We are working hard with the HSE, and are very much supported by the HSE, to augment the GP numbers, particularly in rural areas. This is a short-term response.

Deputy Bernard J. Durkan

We have heard comparisons made with the UK, Scotland, France, Germany, and almost every place across the globe in the last couple of years. We have been compared with New York, Sydney and so on and so forth. They are all having their problems now. They are all having the same issues we are having but they are having them later. We had these starting off a couple of years ago. We should have solved those problems by now. Are we paying enough? I am not talking so much about competing on a worldwide basis but to ensure that the various services provided by the HSE to the general public are sufficient to attract a sufficient number of people to fill the positions at any given time from the domestic market.

Dr. Diarmuid Quinlan

We have very substantial supports from the HSE. We need to view that against this being a global competitive market. I have worked in the UK and Australia. Lots of my younger GP colleagues and older GP colleagues have also gone overseas to seek experience. What we need to try to do is make it attractive for these doctors to return to Ireland and practise in Ireland.

Mr. Fintan Foy

It is about building the resources and supports around the GPs to make those posts attractive. That is the critical area we need to work on.

Deputy Bernard J. Durkan

How quickly can we do that and put it in operation?

Mr. Fintan Foy

There is an urgency about it. The time is now.

Dr. Diarmuid Quinlan

That is why the Department of Health's strategic review, and the necessary resources that need to flow from that, is key. The group should have a short working life and we should deliver on our aspirations in the Shaping the Future of General Practice document.

Senator Frances Black

I thank the witnesses for coming in. Many of my questions have been covered and I do not want to go over them again. There is, however, one point I want to come back to, which Senator Kyne has touched on. I am aware that it is not referred to in the document but it is about students and the points system. For example, I know of a young woman who all her life wanted to become a doctor. She got only 590 points or 580 points in the leaving certificate although she worked hard. I know she would have been a brilliant doctor. Is this points system something that can be looked at? Can there be another way of measuring whether somebody could be a really good doctor apart from the points system, if that makes sense? I just wanted to throw out that as my first question

Dr. John Farrell

Unfortunately, we do not have any control over that. The basic thing is that we do not have enough doctors at all levels in the country. We need to find a way of getting more people in who would enjoy a career in medicine. That would be down to discussions with the universities and expanding places there, and having more people. If we had more doctors then hopefully there would be more doctors interested in pursuing a career in general practice. Unfortunately, we do not have any influence on the points system or on how many places there are in the universities. Again, perhaps this is something that could be brought up with colleagues in education around how this could be addressed.

For those who wish to pursue a career in general practice our job is to provide the education and support for them throughout their professional careers. If more people could be provided in that field and we would be happy to accept them.

Mr. Fintan Foy

If there are different mechanisms to enable more people to go into medicine we would support that, but it is a complex arena.

Senator Frances Black

The witnesses' ask today is for a task force going forward and for that task force to have a strategic review in a timely fashion. How can we as a committee support the witnesses in that? What would they like us to do?

Dr. Diarmuid Quinlan

I would like the Department of Health strategic review to be conducted in a timely and concise fashion. Then we would implement and adequately resource the recommendations to ensure the people in Skibbereen, Lisdoonvarna, Cahersiveen and elsewhere can access a GP and get high quality care in a timely fashion, day or night.

Dr. John Farrell

We have inputted this into the terms of reference and some of the items we have in our Shaping the Future of General Practice document have been incorporated into the strategic review. It needs to happen. The members must all be getting huge numbers of complaints from people being unable to access primary care services in a timely fashion. As I have said, if one has a functioning primary care system the pressure goes off all the other areas of healthcare. That is only to everyone's benefit, including even on a cost basis.

Senator Frances Black

Is there a model or any other countries that have a really powerful model when it comes to GP care and general practice? Is there a model in some country the witnesses would like to copy? If so, what country would that be?

Dr. Diarmuid Quinlan

Scotland is really quite similar to Ireland with population - a couple of major cities and the rest spread across the Highlands and the islands. They have substantially increased their GP training and they have a lot of additional mechanisms to ensure that in rural and remote areas there is a secure supply of GPs and GP care for patients when they need it. That does require innovative thinking. We have incorporated some of those suggestions into our Shaping the Future of General Practice document. There certainly are models from overseas we can adapt part of.

Senator Frances Black

I thank the witnesses.

Deputy Colm Burke

I thank the witnesses for making the time available to us, for their presentation this morning, and for the discussion paper published in October. It has a lot of very good information and it is about planning the way forward.

I am coming from a scenario I saw some five years ago when I was in the UK. At the time there were more than 5,000 GP vacancies there. In the area we were in, there was one practice with some 20,000 patients and all of the GPs resigned in the one day leaving a whole area without any practice whatsoever. Those were the challenges over in the UK. I do not want us to go down that road.

I would like to go over the numbers of people in training. My understanding is that 932 people are in training at the moment. Of those, how many will qualify and will have the full four years done in 2023?

Dr. John Farrell

That will be 285. We qualified 256 this year and there will be 285 next year. We are looking at that kind of figure.

Deputy Colm Burke

Looking what has happened in recent years, and given the number coming out next year is 285, what percentage of those who qualify is likely to go to another jurisdiction to work for a period of time? Is that a particular challenge at the moment?

Mr. Fintan Foy

It is a problem but we do not perceive it as a huge problem. Based on our analysis of the numbers emigrating, it has fallen to single digits in the past five to six years.

Deputy Colm Burke

Are we talking about less than 10%?

Mr. Fintan Foy

Yes, less than 10%.

Deputy Colm Burke

Okay. With 285 qualifying next year the important thing is to take the right steps to encourage them to stay here in Ireland and to make sure there are proper structures in place for them.

Mr. Fintan Foy

Yes. That is absolutely critical.

Deputy Colm Burke

On the numbers, in four years' time how many new people will have qualified? Are we talking about 932? If we take into account the two-year training programme that was referred to, what kind of targets are we setting for four years' time?

Mr. Fintan Foy

We just have to get the numbers correct here. We took 258 into training this year. They will do the four-year training programme and ideally those 258 will stay or will go into general practice, but that is probably not practical. We estimate that in 2023 some 200 trainees will have completed their training. In addition we have the non-EU programme, and hopefully within one year we would have another 100. There would be approximately 300 coming out of the system in 2023.

Deputy Colm Burke

Over the next four years, would the college see itself having 300 coming out every year?

Mr. Fintan Foy

Ideally yes.

Deputy Colm Burke

On a few occasions I have come across people who have found the whole work situation in the hospital extremely stressful and they want to step back into doing GP work. What is the training programme for someone who has spent five, six or seven years in hospital training, who decided it was not for them and decided to go back into the GP scheme? Is the training for them still four years?

Mr. Fintan Foy

No. If they meet a certain criteria, and maybe have been in the system for a couple of years, they will do a three-year training programme. They would do one year in hospitals and two years in practice.

Deputy Colm Burke

What kinds of numbers are we talking about where that is arising?

Mr. Fintan Foy

Those numbers have been increasing over the past couple of years. I do not have the exact figure for this year but I believe it was somewhere between 30 and 40 per annum who would come into the system to do the three-year programme.

Deputy Colm Burke

Were these actually dropping out of the hospital system?

Mr. Fintan Foy

Yes, who decide they would prefer to go down the GP route rather than the specialty route.

Deputy Colm Burke

I have come across people who have been in training for as long as nine years and decided the stress levels in the hospitals, and the demands made on them in the hospitals are forcing them out. They have they decided that life is short enough and that going down the road of GP training is the best road for them.

Dr. John Farrell

The first thing we would do is disabuse them of the notion that general practice is any less stressful than hospital medicine.

Deputy Colm Burke

I accept that. The areas I am talking about are probably the areas that have high litigation levels such as in obstetrics and gynaecology. These are the areas where people are finding it extremely stressful to work. The other is in orthopaedics.

Dr. John Farrell

This holds for all the specialties, including general practice. Patient expectations are, rightly, very high of their healthcare provider. There is stress through all specialties in medicine.

Deputy Colm Burke

Reference was made to doubling the nurses working in GP practices. If we decide to double the numbers of nurses in GP practices, it must be noted there is a challenge at the moment in getting nurses.

It is obviously something I am very much in favour of because there is a lot of work that GPs are doing that nurses are really well trained to do. The problem is that we may end up taking nurses out of the hospitals or nursing homes, causing further problems and shortages as a result. How can that challenge be dealt with?

Dr. Diarmuid Quinlan

Nurses are an invaluable resource in our health service. We have a very substantial cohort of highly skilled nurses in Ireland. It is important that all career options are available to them. General practice is and should be one of those career options. We need to make sure we train sufficient numbers of nurses as we train a sufficient number of GPs. We should make every career option, including the very attractive role of GP nursing, available to nurses.

Deputy Colm Burke

How do we increase the number of training places for nurses to deal with this new demand? If the Department decided in the morning that an additional 2,000 nurses were to be recruited for GP practices, how would that demand be met?

Dr. Diarmuid Quinlan

I do not believe it will be 2,000 overnight. That is what we anticipate will be needed. We know we need that number. It would be an incremental increase. There are many nurses who are not working in clinical work in hospitals. Many of them would be attracted to general practice if there was a training programme to support them and integrate them into general practice.

Deputy Colm Burke

One of the other challenges arising in the medical service is that, because very large companies in Ireland are receiving non-stop complaints from their employees that they cannot get access to GPs, private companies are now taking on GPs in a full-time capacity. Does the Irish College of General Practitioners, ICGP, see that as another challenge we are going to face over the next two to three years?

Dr. John Farrell

It has the potential to be a challenge. One of the things that has happened is that there has been a fragmentation of primary care. There are GP services but some of the health insurance companies are also providing online services.

Deputy Colm Burke

I am talking about big companies like the IT companies, the medical devices companies and the pharmaceutical companies physically employing a GP to look after their employees. Does the ICGP see that as a growing trend because of the problems those companies are having in holding onto staff? This is an additional plus they can offer staff.

Dr. Diarmuid Quinlan

We can look at it in different lights. It shows the skill set that general practitioners have that general practice is attractive in many specialties and many fields across our economy. The workers in those industries need access to high-quality, timely healthcare and their companies are providing it for them. It again comes back to the fact that we simply need more GPs. That is why we need our strategic review.

Deputy Colm Burke

My final point is on the whole issue of the task force. One of the problems I have when committees or task forces are set up is the timescale involved. Has the ICGP talked to the Department about setting out a clear timescale as to when the task force will deliver and set out a clear plan for dealing with the challenges we have?

Mr. Fintan Foy

We have not had a one-on-one conversation with the Department but we have certainly indicated our view in the documentation we have provided and in any conversations we have had. As Dr. Farrell has said, it needs to be very-----

Deputy Colm Burke

What is the ICGP's view on the timescale? In what kind of timescale would it like to see the task force reporting?

Mr. Fintan Foy

It should be no longer than six months. It needs to be very tight.

Deputy Colm Burke

Has the task force formally been set up at this stage?

Mr. Fintan Foy

No. The terms of reference have still to be signed off on. Our hope and expectation is that it will be set up in January.

Deputy Colm Burke

Is there someone within the Department who has taken on responsibility for-----

Mr. Fintan Foy

There is, yes.

Deputy Colm Burke

-----the connection with all of the organisations involved, including the Irish Medical Organisation and the ICGP? Has there been discussion with them to ensure the terms of reference can be signed off on by, for example, the end of January?

Mr. Fintan Foy

I am not aware of discussions with the other organisations but there have been discussions with our group. Our document, "Shaping the Future", probably drove that initial engagement with us.

Deputy Colm Burke

Does Mr. Foy believe we can actually get this signed off by the end of January? If it is not signed off on by all of the organisations by the end of January, it is going to drag into February and then into March. I am a bit concerned about the time it takes Departments to set up reviews and then to get them working.

Dr. John Farrell

If there is one outcome we are seeking from this meeting, it is for people like the members to say that they have listened to people who are trying to provide primary care services on the ground and know for definite that there is a serious issue. We are looking for their support to push this forward because this has to happen. We need the support of this committee and for members to go back to whoever looks after these things and say that this is now urgent. Otherwise, we will not have a functioning primary care service or general practice service for our patients.

Chairman

Dr. Farrell can take it that the committee will support that reasonable call for the establishment of the review.

Deputy Colm Burke

The committee should write to the Minister and ask that timelines be set out for the review to be signed off on, established and got up and running and functioning.

Chairman

While we have not had a formal meeting, it seems the consensus at today's meeting is that we will agree to that. We will move to Senator Hoey. Can she confirm that she is within the precincts of Leinster House?

Senator Annie Hoey

I sure can. The Chair can tell by my flags that I am in my office in Leinster House. I hope I can be heard okay. I will hold the microphone close to me. I thank the witnesses for all of that. Two things jumped out at me. There was reference to suitable premises. There have been conversations in the Joint Committee on Health with regard to having expanded clinical teams, which I believe was the phrase the witnesses themselves used, to provide multiple services in one location. I refer to GPs, nurses, mental health services, physiotherapy and whatever else. I have previously made reference in this committee to the multiple options in the one setting when I was down in University College Cork, UCC. Reference was also made to the fact that we cannot even get GPs in some towns and that services can rely heavily on locum staff. Caherciveen and Lisdoonvarna are examples. How do we square the circle? Are we chasing two different ideals of what clinical practice is going to look like? On the one hand, we are just trying to get GPs into an area while, in other areas, we are trying to expand suitable premises and service provision. Does the ICGP see these as needing to come together as one? How do we square that circle?

I only have two questions. On the second, I was furiously trying to find an exact quote. When people have presented to the Joint Committee on Health, the question of whether we are providing enough training places for medicine graduates in Ireland has been raised. I hope the witnesses will forgive me but I cannot find the exact quote. I am nearly positive that, in conversation with other representative bodies, we have been told that enough places are being provided. This was in reference to the overall number of graduate places being offered. The ICGP is saying that we need to increase the number of GP places specifically. Does this tally? Is it that we are providing enough graduate training place but that we need to increase the number of GP training places and reduce the number in another area? Is it that we are simply not providing enough graduate training places overall, despite what other speakers have said before the Joint Committee on Health?

Mr. Fintan Foy

I might take the Senator's second question, which had regard to training places. From our perspective, it all depends on the output from the medical schools. Somewhere between 800 and 1,000 graduates leave medical school and go into intern places every year. They then have somewhere between 13 and 16 different specialties to choose from. The capacity is built around that. From our perspective, getting 350 trainees out of that per annum by 2026 is probably the limit. This goes back to the previous discussion. To increase the numbers going into training places, the numbers going into medical school must increase. Based on the input into medical schools at the moment, we are probably at full capacity at 350.

Dr. Diarmuid Quinlan

If I may address Senator Hoey's first question, providing general practice services across the country is a big challenge. Our proposal is multifaceted. We certainly need substantially more GPs, GP nurses, phlebotomists and healthcare assistants. We need to very substantially expand the GP multidisciplinary team. Clearly, we need premises with greater footprints to house those healthcare professionals. As Mr. Foy has referenced, we also need to look at how to encourage graduates of Irish medical schools to select general practice as their preferred career.

The international evidence is clear. If we want people to choose the specialty of general practice, they need to be exposed to general practice during their graduate training. In Ulster University 30% of the undergraduate training is delivered in general practice. We need to substantially resource our universities to develop a pipeline to deliver our graduates into Irish general practice.

Senator Annie Hoey

We are caught between the chicken and the egg. The medical students I know who either went straight in at undergraduate level or through graduate entry medicine have left because of the pressure on the system. I have a number of friends in their late 20s and early 30s who have done this. This is in general and not just on the GP system. We are caught in a never-ending loop of pressure on the system causing people to leave and people not leaving once we deal with the pressure on the system. If we do not get people to stay we will not deal with the pressure in the system. The witnesses put forward proposals specifically regarding GP practice and how they would close the loop. Do they feel there is political will to support this? They have come before the committee and we are supportive but do they think there is a genuine will or interest to deal with this? This comes up in every sector. People are leaving because there is too much pressure, then we cannot get people in to deal with the pressure and, therefore, we cannot keep people. Not to be a miserable Mavis on this but is this part of a perpetual system we are trapped in for the next while? Do the witnesses think if genuine efforts were made to take on their concerns, specifically with regard to the GP sector, that we could start undoing some of the damage that is being caused by people leaving?

Dr. John Farrell

I have found general practice a very rewarding career but there are challenges for people coming into the specialty regarding the provision of premises and setting up a practice. The Senator's point is well made. People are leaving the system because it is not attractive. It behoves us, at this stage in our careers and as a college, to make the situation better and to try to improve facilities for people. Our primary role is in education of GPs but we have a wider remit to make sure there are enough GPs in the country and that all areas are serviced. People are leaving because the system is under a great deal of pressure. We have seen this at consultant level and public health level. It is at all levels. One issue is that we do not produce enough doctors and we are certainly not producing enough GPs. This means we need to increase capacity in medical schools. This means more funding for universities and increased hospital places. It is a serious issue. We have all been aware of it. Anyone who has been around for any length of time is aware that these issues are recurring. We are trying to approach it from a GP point of view. As I have said, if we have a functioning primary care system many other problems will be sorted. This is the main point we want to make.

Senator Martin Conway

I thank the witnesses for their attendance. This has been a useful engagement. Deputy Burke asked about the task force and the terms of reference. Have the witnesses been given sight of draft terms of reference for the group that will be convened in January?

Mr. Fintan Foy

Yes, we did two or three weeks ago. We were asked for our comments, thoughts and inputs into the terms of reference. We returned them to the Department.

Senator Martin Conway

Did they suggest significant changes in their recommendations?

Mr. Fintan Foy

We suggested that perhaps the were a little too broad and we tried to narrow them. It was useful that we had put together the Shaping the Future document and we were able to input it. In some ways, if terms of reference can be narrowed down they are easier to deliver.

Senator Martin Conway

Has the ICGP been given an indication as to who will chair the task force?

Mr. Fintan Foy

Not to date.

Senator Martin Conway

Do the witnesses have any preference?

Mr. Fintan Foy

No. In a sense from our perspective we just want to make sure that GP voices are loud and clear on the strategic task force. As we have said many times this morning we want it to start as quickly as possible.

Senator Martin Conway

With regard to GP visit cards specifically, the departmental and Government target is that there would be free GP access for children aged six and seven by the end of this year and that next April, there will be further changes to the qualification criteria. Given the pressure that GPs are under, do the witnesses think it is wise for the Government to proceed with the changes in April?

Dr. John Farrell

As a practising GP I have not been informed of the timeline for the roll-out of the GP visit cards. I do not know exactly when it will happen. All we can say is that there is significant pressure on the system and it is likely that the increase in the number of doctor visit cards will increase the pressure on the system.

Senator Martin Conway

When the changes made in recent years came into effect, did GPs notice a significant increase in the traffic flow through their practices in the immediate aftermath?

Dr. Diarmuid Quinlan

We know from robust research that when the GP cards for children aged under 6 were introduced it increased attendance of that cohort of patients by 30%. We know a similar uplift will happen in the demand for consultations for children aged between six and nine. We have quantified this at a minimum of 640,000 additional consultations a year, which will require 120 whole-time equivalent GPs. This is the demand it will place on the system.

Senator Martin Conway

I have a question on doctors co-operating. There are some examples, particularly in rural Ireland, where doctors have come together to share back-office and secretarial support. There are still quite a few GPs who have not bought into this concept. Do the witnesses have figures on the numbers that are part of a shared back-office co-operative approach and those who are still sole traders for want of a better description?

Dr. Diarmuid Quinlan

Approximately 20% of GPs are single-handed GPs and another 20% approximately are small practices with two doctors. To some extent it is not that they have not bought into a larger model. For those working down in the peninsulas of west Cork or west Clare or on the Inishowen peninsula the option may not be available to work in this way.

Senator Martin Conway

I understand that.

Dr. Diarmuid Quinlan

In west Clare there is collaboration among the GPs.

Senator Martin Conway

There is and it works very well. I am from that area. There are still GP practices in the same area that have not signed up to it, bought into it or whatever phrase we want to use. There could be three practices in a ten-mile radius of each other that are co-operating but there could be another practice within the area that could easily be part of the loop but is not. I am trying to understand why a practice would decide not to do so. The benefits seem quite obvious.

Dr. John Farrell

GPs are independent contractors and have an individual contract with the primary care reimbursement service and GMS for providing medical card care. They do not have to join.

Senator Martin Conway

I totally get that but why is it not attractive for them to do so? Is there anything that can be done that would make it more attractive?

Dr. John Farrell

I am not sure. Does the Senator mean out-of-hours co-operation?

Senator Martin Conway

I am aware of an example where three GP practices have come together but within that community there is another practice that did not join. It does not make sense to me because there is safety in numbers from a range of perspectives. It seems to be a good model and I would like to see it implemented where possible. Dr. Quinlan pointed out there are areas of the country where it is not possible.

However, where it is possible, I would like them to buy into it so there would be that type of collaboration.

Dr. John Farrell

We cherish the diversity. I cannot speak for those people. I do not know. It does not suit everyone to work in a larger group where there might be different challenges.

Senator Martin Conway

Lisdoonvarna was mentioned earlier. Unfortunately, I was not present at the time. Lisdoonvarna is a unique example because the village and the immediate area are accommodating almost 1,000 Ukrainian refugees who are displaced. This creates a special case for an escalated resolution to the GP situation, which will become a problem in March. Has that been taken into consideration in the discussions surrounding Lisdoonvarna?

Dr. Diarmuid Quinlan

I am not privy to conversations on Lisdoonvarna but I know the challenges faced are widespread. We know that in the past three years, the HSE has spent €1.3 million on GP locums on the island of Achill, the number of GPs in towns in north Cork has fallen from 18 to 12, the number of GPs left in Cahirciveen is very small and Skibbereen has lost a substantial number of GPs. This is all against the backdrop of an increasing population in Ireland so the challenges are enormous and widespread across our rural system.

Deputy Michael Creed

I welcome Mr. Foy, Dr. Farrell and Dr. Quinlan. My interest was piqued by Dr. Quinlan's comments about the Newmarket, Kanturk and Boherbue area, which is in my constituency, and the problems of GP practices in rural Ireland. It is true based on the experience of other members and my own experience because I represent a diverse constituency that goes from Ballincollig, which is the largest town in the county, to the more peripheral rural areas that this is not just a rural peripheral issue but is a national issue. More broadly, it is a global issue. There is a shortage of qualified medical personnel. Anybody who visits our hospitals or uses our out-of-hours GP call-out service will be aware that were it not for international expertise, our health service would grind to a halt. We have problems with retention and go all over the world to recruit GPs from other countries such as South Africa, India, Bangladesh or the Philippines where they have been trained at considerable expense. There is a global shortage of medical personnel across all areas.

All of us are also aware that there is a deficit of skilled services be they in hospitality, homecare or construction so we should not beat ourselves up and think this is something we suffer exclusively from. There is a global dimension to it - not just a domestic or even a rural or urban dimension to it.

The question is whether the investigation the Department proposes will address the issue in a meaningful way. I will pose a few questions and make a few observations in this context. It costs the Exchequer a considerable amount to train a medical doctor regardless of whether he or she then decides to pursue general practice or a hospital-based career or opts for employment in other areas where his or her qualification can be used. This is a big challenge. Do our witnesses accept that given the considerable cost to the Exchequer and if this investigation by the Department is to make any meaningful progress on it, it is time to introduce a contractual obligation on the graduate to work in the Irish public health service for a number of years given the Exchequer pays a substantial amount per annum to train a medical graduate? This is not a radical proposal. It is something other countries in a similar development phase to Ireland such as Israel and Canada have considered and implemented. Should we oblige medical graduates to commit a certain number of years post qualification to working in the Irish public health service as a way of addressing value for money in respect of the expense the Exchequer commits to their training and dealing with retention?

I listened with interest to the numbers. Eight hundred to 1,000 graduates come out per annum. I do not have the figures but the witnesses might educate me on this. I suspect that approximately 60% of the intake in any given year in our universities is female undergraduates. If out of 1,000 graduates, 600 are female, for understandable reasons such as child rearing in particular, many of those will either disappear from the workforce for a number of years or significantly reduce their hours. How many graduates do we need to train to have the equivalent of 1,000 whole-time employees in the health service per annum because a figure of 1,000 is not delivering if after a number of years, a substantial number of those graduates will not be working in the public or private health service? The feminisation of the profession is not a bad thing but it has consequences. What intake is needed to reach to secure the equivalent of the prominent provision in the health service?

Dr. Diarmuid Quinlan

I have some skin in the game because three of my sons are in college. It would be challenging to say that medical graduates alone should be compelled to remain in the country when this would not hold for any other graduate. There would be an issue with equity. However, we all know that in Australia, graduates pay for their education through supported loans. That is a larger conversation that we might have with the educational institutions. I know University College Cork, which is my own university, has a substantial number of non-EU medical students, who pay well north of €40,000 per year for their education and this subsidises the education of Irish and European medical graduates substantially. The funding of undergraduate medical education is a complex issue. Compelling graduates to work in a system that is very challenging might have the unintended consequence of dissuading people from choosing medicine in the first place.

Regarding the Deputy's second point about how many doctors we need to replace a whole-time equivalent, increasingly male and female graduates are looking at family-friendly options and this would include shared GMS contracts. We also need to look at their career objectives. Increasingly, our doctors want to do part-time clinical work, part-time research and part-time medical education. Increasingly, our younger and older doctors are choosing to work a blended or portfolio career where they have all of those issues. The evidence is that this helps prevent burnout. To answer the Deputy's question, one person entering GP training and working solely in general practice is increasingly less likely to be the case in the future so we need to plan for substantially more GPs, which is why we gave the figures earlier. Dr. Farrell might allude to the figures again.

Dr. John Farrell

Fifty-four percent of GPs are female while 46% are male. Of those aged under 45 in practice, 67% are female. We spoke earlier about whole-time equivalents, a point raised by Deputy Cullinane.

We currently have 4,250 people in practice, which equates to about 2,800 full-time equivalents. To get to the requested 6,000 doctors, that would be the equivalent of 4,000 full-time equivalents. It is not 6,000 full-time equivalents; it is 4,000 full time equivalents. I wish to clarify that point. The Deputy is quite right in asking do we have an answer to his question of how many graduates we need. The point about it is that the universities can provide only so many places. We have somewhere between 800 and 1,100 medical graduates every year. As Mr. Foy said, not all of those will choose a career in general practice. We are hoping to get at least a third of them, 350, attracted into general practice each year. The first two years after qualification are critical for retention. That is why we must make the posts attractive for people to stay. Rather than trying to attract them back, it would be much more economical and efficient to concentrate more on retention. We need to retain the people who are in.

I appreciate that there is a kind of rite of passage with people going away for 12 months or 24 months to sunnier climes after they qualify and after their internship. A significant percentage of those come back after a year or two; that is not the issue. We need to retain the people after graduation from a national training programme such as we are now providing. We need to encourage those people to stay in practice and the first two years are critical in that. That is why we need support for rural practice and inner-city practice. The key point is to ensure patients have high-quality, immediate general practice care to improve health outcomes.

Deputy Cathal Crowe

I welcome our guests this morning. I apologise. There are four committee rooms down here. I was at the Joint Committee on Transport and Communications and so this is a nice break away from talking about airports.

I have read the briefing notes. Unfortunately, I was not following most of the debate here. The witnesses mentioned rural doctors a few times. Last month the Clare Public Participation Network published a poverty report specifically on the county of Clare. To my knowledge this is the only county-related, county-confined poverty report we have at the moment in the country. They are all national metrics of poverty, but this is the only county-specific one. It highlighted that our access to GP care in Clare is 33% below the national average. We have beautiful towns and villages along the Wild Atlantic Way, lovely to visit in the summertime but maybe not the most attractive place to live and set up a practice after coming out of college. A number of GP posts have been advertised but apparently nobody is willing to fill them. What could best incentivise a young doctor to come to the west of Ireland to a county like Clare, Galway or Mayo and set up to have his or herfull career there? As people who know this best, what would the witnesses recommend?

Dr. Diarmuid Quinlan

The west of Ireland and the entire Wild Atlantic Way is really a phenomenal place to live and raise a family. If we put in place the correct resources, we will have no difficulty attracting GPs to work in these areas. The major challenge for doctors is the inability to secure holiday locums. Almost no doctor will take up a post where they cannot secure reliable locum relief so they can take holidays with a young family. A Cork town has recently lost a single-handed GP who was there for over ten years. She has left and closed her practice specifically because of the inability to secure a holiday locum. That is a major issue.

There are other issues such as practice premises and rural supports. It is more challenging to work in rural areas where the expectation is the GP is dealing with a much wider range of issues. If somebody gets seriously injured on a farm accident in my area, the ambulance would be there within ten minutes and bring them to the university hospital which is ten minutes away. In areas such as north Cork, the air ambulance helicopter comes in and rescues that person, but the GP can be there for several hours supporting them and providing onsite care. It is a much more challenging environment for a GP and we need to support and resource that appropriately.

Deputy Cathal Crowe

I thank Dr. Quinlan for his perspective. Do the out-of-hours pooled resources such as ShannonDoc, need further bolstering to support a GP, particularly in a largely rural county?

Dr. Diarmuid Quinlan

I am very familiar with SouthDoc. The majority of the GPs across Cork and Kerry work in SouthDoc. I worked there, myself, last Saturday. With a shrinking GP pool and increasing demands it is becoming increasingly challenging to do that. We are asking doctors who are working during the week to work in the evenings and at weekends. That is increasingly challenging and it is a disincentive. It is particularly hard for my colleagues in rural areas of Cork and Kerry rather than in a city. It comes back to the issue that we simply do not have enough GPs. If we had a sufficient number of GPs, it would share the burden and mean patients would get timely access to high-quality care. It all comes back to the GP workforce deficit we are currently experiencing.

Deputy Cathal Crowe

Dr. Quinlan suggested that there should be encouragement of graduates to remain for two years. Would he go as far as to say that it should be compulsory?

Mr. Fintan Foy

I do not think we said that.

Dr. Diarmuid Quinlan

Deputy Creed raised that issue. I believe that compelling people to stay somewhere may have unintended consequences.

Mr. Fintan Foy

We need to make it attractive for people to stay rather than compel them to stay. I do not think compelling them to stay work because people will still leave.

Deputy Cathal Crowe

Those in the field of veterinary medicine are able to quantify how many young Irish people go overseas to train as veterinary surgeons. How many Irish people go overseas to train to be medical doctors?

Mr. Fintan Foy

I do not know the exact number, but it would be relatively small.

Deputy Cathal Crowe

Presumably, most of those do not return to practise here.

Mr. Fintan Foy

The majority of Irish people who go overseas to study medicine would return to Ireland to do their training.

Deputy Cathal Crowe

How many Ukrainian doctors have registered to practise here?

Mr. Fintan Foy

I would say it is virtually nil. It is very difficult for them to register because of the steps that need to be taken through the Irish Medical Council. I mentioned earlier that the Minister has provided funding to enable them to do the English language assessment and things like that. For someone coming directly here from Ukraine it would be very difficult to register immediately.

Deputy Cathal Crowe

Would there be merit to them operating on a different contract as a roving, travelling GP to the Ukrainian community? In County Clare, there are 3,700 Ukrainians but very few of them have been able to get onto the local practice lists which are just full. There is probably some logic to having someone with their language and skill set travelling to different accommodation centres. This is not a scattered population. In most counties they are usually based in four or five different centres. Would there be merit in having somebody on a contract specifically to provide for the healthcare needs of that population?

Dr. Diarmuid Quinlan

I can certainly see merit in having Ukrainian GPs supporting the Ukrainian community in Ireland. There is a very substantial challenge in the Irish Medical Council allowing any overseas graduate to register in Ireland. We need to ensure that the quality and standards are comparable to those in Ireland. None of us would like to see our Ukrainian population obtaining care from people who are not registered or qualified to provide care in this country. We would be certainly open to working with the Irish Medical Council and this committee to expedite the steps necessary to make that happen.

Mr. Fintan Foy

We could help with the education relating to that. That is our role.

Deputy Cathal Crowe

There are two Ukrainian GPs in county Clare and a similar number of dentists. We have an obstetrician. They are all eager to practise but are finding it very convoluted to get to practise. As I said at the start of my contribution, Clare is 33% below required GP coverage when compared with other counties. It would make an enormous difference to have them operating in the community. Even if it were just to provide a medical service to their own people in their own language it would be immense.

Nurses often tell us how difficult the job is with conditions leading to burn-out. A few years after entering general nursing, many of them want a pathway out of it. They go overseas, seek promotion, try to become a GP practice nurse or find some other pathway out of the ward system. Is there logic to having an accelerated course if a nurse wishes to become a medical doctor apart from the postgraduate training courses currently on offer? If someone has spent seven, ten or 15 years in the ward system in an acute environment with all that incredible skills set - doctors might not like me saying this - I believe they could probably do everything a doctor can do apart from writing prescriptions.

I know there are two conflicting realms here, but surely there should be an accelerated pathway for somebody who has the desire, after years of nursing experience, to become a doctor. I apologise to any doctors tuned into this.

Dr. Diarmuid Quinlan

As an interim step, we would welcome those nurses becoming GP nurses and we would provide the education and supports to induct and to support them in general practice. They would be welcome with open arms in general practice. If they want to go to medical school, that is a conversation the nursing bodies might need to have with the medical bodies.

Deputy Cathal Crowe

The ICGP would back them, though, would it not?

Dr. Diarmuid Quinlan

We would back-----

Mr. Fintan Foy

The accelerated programme exists already through the four-year graduate entry programme. Some nurses decide to leave nursing and to go through that four-year programme rather than the traditional five-year or six-year programme.

Dr. Diarmuid Quinlan

The Deputy's local University of Limerick has a graduate entry programme so would, I am sure, snap them up with open arms.

Deputy Cathal Crowe

This deserves more exploration. I just happen to have met people in veterinary sciences recently. If you have a primary or master's degree in agricultural science, you can, through an accelerated pathway, become a veterinary surgeon. It is a whole different realm of healthcare but, in the context of capacity building, there are many superb nurses and doctors, and the chasm or gap between them, to me, is non-existent.

Dr. Diarmuid Quinlan

There are many nurse prescribers in this country who do an excellent job. That distinction is blurred somewhat as well. We would encourage more nurses to upskill continuously.

Deputy Cathal Crowe

Admittedly, I say that through the eyes of a patient. I am a teacher by profession. Some might ask what is the difference between a teacher and a speech and language therapist. I come with that baggage but it is-----

Dr. John Farrell

We might have to chat to the Deputy afterwards.

Deputy Cathal Crowe

No problem.

I thank the witnesses for everything they do. In particular, their comments on rural doctors and how to encourage them are very welcome. Those comments need to be digested more.

Dr. John Farrell

As to what the Deputy said about practices being busy, 90% of practices have reported that they are busier now than they were before Covid. There is a pent up demand there because there was lots of telemedicine and telephone consultations during Covid and people want to be seen, want to meet their GP and want to discuss their health issues. We have seen 90% of practices now reporting increased workload levels. The opposite side of that is that 40% of GPs could not take annual or sick leave in the past 12 months. That is a huge amount of leave. As for incentivising people to go into rural practice or general practice anywhere, if people could not take time out because of sickness or to get an operation done or whatever the case might be, that is a disincentive. Those are the areas we need to address.

Deputy Cathal Crowe

That is definitely massively off-putting.

Dr. John Farrell

Yes.

Chairman

I think a number of Members concentrated on the fact that we have 2,807 GPs and we need 6,000 by 2028, in six years' time. From what we have heard this morning, unless a plan is put in place, we will hardly reach that and it is clear, even with the best will in the world, that it would be very difficult to reach that plan. There were a number of questions about the capacity of the current system. Dr. Farrell, did you say that the current capacity would be 350, maximum, within the system?

Dr. John Farrell

Yes. The plan is for 350 training places by 2026. Going back to the figures, we have more than 4,000 doctors working in general practice, which is equivalent to 2,800 whole-time equivalents, and we need to get to 6,000 doctors working in practice, equivalent to 4,000 whole-time equivalents. That is what we need. It is not 6,000 whole-time equivalents; it is 4,000 whole-time equivalents. It is still a huge ask but it is less than what we were referring to earlier.

Mr. Fintan Foy

Going back to your point about the 350, Chairman, that is what we would see the capacity being, based on the numbers coming through the system and coming out of medical schools and into training programmes. That is what that capacity is built around.

Chairman

You are talking about 9% of those who go on to be GPs, so that is 350 you are saying that-----

Mr. Fintan Foy

We would like to see a great many more come directly from their intern years into general practice. At present it is only approximately 9%.

Dr. John Farrell

That is 9% of the people who are leaving internships applying. There are other people applying who have already done a number of years in, say, hospital medicine. As for the total number applying, we have had a record number of applications this year, more than 950. That is for 285 places starting next July. However, the target is 350, and we feel that that is the maximum within the current system. It is within the broader university population and the broader number of medical graduates, of whom there are about 1,000 every year.

Chairman

Will we reach the figure we are looking for if we have that maximum number? If there is a magic wand such that the Minister turns around tomorrow and asks for the colleges to be filled to capacity, can the ICGP do that? Does it have the personnel? Does it have the space to put those people if it had those interns who were available to go into-----

Dr. John Farrell

We would need increased numbers of general practice trainers and access to more suitable hospital posts for those doctors to address specifically the GP workforce issue.

Chairman

It is doable. Is that what you are saying?

Mr. Fintan Foy

It is doable if the resources are aligned with it. It is doable.

Chairman

You are saying that the first point of reference or contact is with the GP. The big challenge, as Members have mentioned, is poverty. Deputy Cathal Crowe talked about poverty and the poverty index in Clare. Realistically, in a lot of cases poor people cannot get a GP, and it has been mentioned that that is the case not just in rural Ireland but also in urban areas. If poor people cannot get onto a GP list, where do they go then? In a lot of cases they go to the hospital and, of course, that is frowned upon and they are told to go to their GP. If, however, they do not have a GP, that is the-----

Dr. John Farrell

Absolutely. That is the crux of the issue, that is, that there is not enough capacity in the system at the moment. We really appreciate the invitation to come here today. Our call to the committee - I thank Deputy Cathal Crowe for saying this - is that we would have its support in order that the strategic review can take place over a short timeframe and that it will produce solutions to this problem. That will go some way towards addressing the problems not just in primary care but throughout the whole healthcare system.

Chairman

For the people going into medicine and the graduates, it is a long time to go through a course without an income. Is that an area we should be looking at in the context of supports? The cohort going into medicine in Ireland in the 21st century either has to have money or has to know someone who has money to get into medicine. Is that not the case?

Dr. John Farrell

Or they borrow it. I have been involved in GP training for the past 30 years and we have had a significant number of people going into graduate entry and coming out after four or five years with loans of €100,000, as happens routinely in America. It is really hard for those people then to turn around and to look for a mortgage and to set up a practice, so they will take work where they can get it. However, they are then asked to take on the burden of setting up a practice and buying another premises. They just will not get that under the financial guidelines now, so they have loans of €100,000 and the intern salary is now €35,000. It is poor to start off. Those people then come out of medical school with those loans and have that repayment capability. Then they are asked when they finish after another four years' training to set up in practice and are told they will need to rent buildings. We just need to look at this and ask how we retain those people in practice and how we can help them set up in order that the patients are looked after.

Chairman

The question I am asking is what additional supports we need to give those graduates going through the system. We have had people talk about student nurses. Trying to get accommodation if going to college is a huge barrier to people. I am asking what happens if they do not have money. Dr. Farrell says they can borrow it. That is not always easy either. The cohort that can actually go through the college system at the moment is very narrow and we need to broaden that if we are to encourage more people. There was mention of what other skills they will need. Clearly, empathy is a skill that every doctor should have, but that is not included in their points if they go for a postgraduate course or whatever else, so there are additional things we need to look at in this regard.

We need to be looking at a package of elements, not just the doctor's surgery and so on. We must first train people and encourage them to stay in the system so that they feel that what they are doing is worthwhile. We also need to broaden the profession to other backgrounds. It should not just be rich farmers' sons and the children of doctors or others of wealth. The system should be open to everyone in society. We should be making it easier for people.

Dr. John Farrell

It is a wider societal issue. We would support what the Chairman said.

Dr. Diarmuid Quinlan

We could do with putting in place supports to enable and help people from deprived and minority communities to go to college. This touches on all of the issues the Chairman raised. They need such supports to make college feasible for them. We would then have a workforce that was representative of our community.

Dr. John Farrell

Which is becoming increasingly diverse. We would support such initiatives.

Chairman

I will let me colleagues in in a moment. It is primarily poor people who are being impacted, although I am not saying that people from other backgrounds cannot get doctors. We are training people at considerable cost, but they are going to more developed and wealthier countries while we are taking doctors from poorer and less developed countries. There is something wrong with this. We need to consider the overall system. The best way of addressing the first point of contact issue is to have prevention rather than cure, which is the medical model in Ireland. That is a larger discussion, though.

Next are Deputies Cullinane and Shortall.

Deputy David Cullinane

I acknowledge the good work done by the ICGP, GPs, general practice staff, including practice nurses, and all those who work in primary care. We accept that, if we get primary care and the relationship between it, the enhanced community care system and community care right, we can take substantial pressure off our acute hospitals. What is happening in emergency departments is stark. A HIQA report out today again shines a spotlight on how bad the situation is. If we look at emergency departments solely through the lens of what is happening in our acute hospitals, we miss the point that many people are in emergency departments because they cannot access care elsewhere.

If we get this right, we can start dealing with the challenges across the healthcare system, but we must be honest about where we are with general practice. I have listened carefully to what has been said, so what I am saying is not meant to paint a negative picture, rather to point out the stark reality of our situation. We have an ageing profile of GPs, as acknowledged by the witnesses, and there is increased demand on general practice. General practice is evolving constantly and we want it to do more, but we do not have enough GPs, ancillary staff or the necessary infrastructure to meet existing demand. A younger generation of graduates want something different - a better work-life balance and greater flexibility. Our GP contract is, to say the least, archaic and needs to be re-examined completely. I hope that the expert or strategic group that is being established will examine all of these matters. Targets are being set for the number of GPs we need. We know what we need, but we have no plan to get there. It strikes me that we have a plan without an engine, which means it will not get far.

In a few months' time, we will have the single largest transformation of free GP care in the history of the State, when 400,000 people will be issued with GP visit-only cards, which I imagine will place more demand on the system. I believe the witnesses cited a figure of 600,000 plus consultations. Workforce planning will become a problem in this area of healthcare. We have discussed workforce planning in respect of other areas of healthcare. It is the single greatest challenge facing the system. Despite all of these challenges and capacity deficits, though, I see no plan of substance. The ICGP has targets and knows what needs to be achieved, but I do not see the resources or capacity required. We will not train enough people or get close enough to the other targets to achieve any of the objectives and targets that the ICGP has set, which I imagine are based on need.

Keeping with the metaphor of a plan without an engine, and given the capacity constraints and that, in a few short months' time, we could be looking at significant additional pressures being placed on GPs because of the issuing of more GP visit-only cards, is it possible that the system could crash? Perhaps "crash" is too strong a word, but will we be facing more pressures on top of what we already have?

Dr. John Farrell

There will be significant additional pressures. The future is not as bleak as the Deputy has set out, though. We have increased training numbers by 60% in recent years. We have a target of increasing numbers to 350 in the relatively short term. We need to reach the figure of 4,000 full-time equivalents, which will probably necessitate 6,000 doctors working in general practice. There is no doubt that, as we have seen with the under-6s-----

Deputy David Cullinane

I am sorry. I hate to interrupt, but we had this discussion earlier and it was accepted. I explicitly asked whether we would reach the target. I have been told that we are facing into 500 whole-time equivalent retirees, so I am building that number into the target. We can accept that there are significant challenges in meeting these targets.

Dr. John Farrell

The Deputy is correct to say that there is not sufficient capacity in the system, but in our role as an educational body, we are doing our bit-----

Deputy David Cullinane

The ICGP wants to be more positive and its job is not to have a bleaker picture painted, but we have to be frank and honest about where we are. This will happen quickly. There is no point in returning to us in six months' time to say that the system has crashed because we have not put the foundations in place.

Dr. John Farrell

That is why-----

Deputy David Cullinane

If I could just make-----

Dr. John Farrell

-----we started this discussion.

Deputy David Cullinane

Exactly.

Dr. John Farrell

People like Dr. Quinlan and I who have been working in practice for a long time have realised that there are serious capacity issues within the system. We have written this discussion document and we have got some traction, insofar as we have been involved in the terms of reference of the strategic group. Our job today is to-----

Deputy David Cullinane

Dr. Farrell has made that point several times and we can support it, but it strikes me that we are putting the cart before the horse. All of this should have been done first. We should have been considering putting all of these additional capacity elements into the system. We could then have started looking at expanding services. Mr. Foy or Dr. Quinlan stated that we probably needed 120 additional GPs - I imagine those would be whole-time equivalents - to meet the demand that was coming in April. Is it possible to get that number by April?

Dr. Diarmuid Quinlan

No.

Mr. Fintan Foy

Not by April. Based on some of the metrics discussed earlier, we hope to achieve that number by the end of the year, but doing so by April would be difficult.

Returning to the Deputy's interesting metaphor of a plan without an engine, many parts of that engine just need to be pulled together, and can be pulled together, to enable the plan to run properly. All of the parts are there. They just need to be joined together.

Deputy David Cullinane

Its parts are a contract that will take some time to negotiate, a doubling in the number of practice nurses, more career pathways for nurses to advanced nurse practitioners working in general practice, an increase in training places, and ensuring that we do not leak more doctors abroad. There are many pressures and challenges, but I do not see a coherent plan. I accept that the ICGP has presented us with the bones of a plan and that a strategic review group will be established. I wish the group all the best and this committee will support it in whatever way we can. However, Ireland has embarked on an ambitious plan to expand free GP cover without having the engine in place. That is my concern.

Dr. John Farrell

The patients will still be looked after, but what it will mean-----

Deputy David Cullinane

Waiting lists.

Dr. John Farrell

Yes. Anyone who is sick will be seen. That happens. People go to emergency departments and find that the waiting times are longer than they expect. Wait times there are not on target. I would not say that the same thing would necessarily happen with general practice. People who are sick and parents who are worried about their sick children will still be seen promptly, but it means there will be a deferral of more routine care.

Deputy David Cullinane

I will make a final point, as I must attend Leaders' Questions. I want to see universal GP care.

I want to see more people with free GP cover as well but if we serve people initially where this happens without the resources in place and they then end up waiting longer, possibly weeks in some cases, to see a GP, that could sour them quickly, which would be a mistake. We need to get it right and all I am saying is if we do not put the foundations in I am a little concerned about what might happen and people's judgments on the ability of the political system to deliver. It is really important we get this right. I am sorry but I have to finish there.

Deputy Róisín Shortall

There is all this talk about a plan without an engine. My problem is that I do not see the plan. We can put an engine in place later but there is no plan there at the moment for general practice and that is the big problem. Indeed, we have been talking about this at this committee for a long time. There is no workforce plan in existence and that has been the huge gap and the reason we are now struggling. Even though money is being provided for different new services, we cannot recruit and money goes unspent. The biggest challenge within the health service is having a realistic and meaningful workforce plan.

There is a lot of talk about rural areas with a lack of GPs. As somebody who represents a disadvantaged urban area, as indeed the Chair does, we are acutely conscious that there are vast tracts of disadvantaged areas in urban Ireland that do not have GPs. The inverse care law says that the more health services are required, the less likely an area is, if it is disadvantaged, to have them. The model just does not work for disadvantaged areas because the buildings are not available and people cannot invest in local buildings.

In trying to get to the root causes of some of these logjams, there is something we have not talked about yet, which is the policy on the funding of medical schools. That policy is contingent on medical schools taking in large numbers of non-EU students, in particular. The fees for non-EU students are enormous. The funding model is based on substantial receipts from those students and that operates to the disadvantage of Irish students who are trying to get in; including the kind of students the Chair was talking about. We do not have a shortage of people who want to work in healthcare. There are these logjams along the way. Thousands of school leavers apply to get into medical school and they do not get in because there are not sufficient places. A large percentage of those places goes to people who pay big fees to bring money into the medical schools. That has not been referenced and it is a significant factor.

The other issue is why graduates are not staying here after they qualify. What research has been done on that? I asked a group of graduating GPs a number of years ago if they would stay in Ireland if there were premises provided for them and the vast majority said they would. They said they would be more than happy to do that. We know, and Dr. Farrell said himself, that after a long training they have loans to repay and all so on, and the vast majority of them are not in a position to fund premises for themselves. The Chair mentioned this. Whatever about people from less affluent backgrounds getting into medical school, they certainly do not have money to get a premises. This has been opposed by a lot of GPs who have invested in their own premises down through the years. I understand people being concerned and not wanting the model to change. Does Dr. Farrell accept that there can be two different models? There is the model that a GP invests in him or herself maybe in a group practice or that kind of thing but there has to be a different model, which is a State-funded premises that can be used so that newly qualified GPs can go into and work in those premises. Does Dr. Farrell accept that many GPs graduates want to be employed in premises provided by the State?

Dr. John Farrell

I appreciate what the Deputy is saying. The honest answer is that I do not know. People still value their independence-----

Deputy Róisín Shortall

There could be a dual system.

Dr. John Farrell

There could be, yes.

Deputy Róisín Shortall

I am not suggesting for a moment that existing GPs or their practices would be undermined. I have always been of the view that the contract should provide funding for premises. If a GP is providing his or her own premises, that should be recognised but equally if a GP cannot provide his or her own premises, it should be provided by the State.

Dr. John Farrell

There are exactly the sort of points we feel need to come up. This is why this is so critical now. The system is not working at the moment and everyone knows what is happening on the ground. This is why we need this group to come up with these sort of ideas. We have mentioned bricks and mortar in this and the footprint and all that. They are the sort of issues that need to be discussed at this high level to come up with options.

Deputy Róisín Shortall

We need to go very wide on this. People have raised the point there about employment or premises but I was looking at what the Minister has said recently on the shortage of GPs. He starts responses to Dáil questions by stating that GPs are self-employed practitioners and, therefore, may establish practices at a place of their own choosing, that there is no prescribed ratio of GPs to patients, and that the State does not regulate the number of GPs that can set up in a town or community. That strikes me as the Minister washing his hands of responsibility for the provision of an adequate number of GPs, and it is because of that model of self-employed GPs who are private practitioners. We do not need to interfere with that but we need another stream so that the Minister will look across the country, identify the need and essentially take responsibility for the provision of general practice. That is not happening at the moment.

Dr. John Farrell

Let that be part of a strategic review. That is a potential solution that might answer some of the needs of our younger graduates. We are not opposed to anything that has been raised. What we want to do is to facilitate and be part of that discussion.

Deputy Róisín Shortall

Has there been research done or has anybody asked newly graduating GPs why they are emigrating?

Mr. Fintan Foy

We need to correct that fact. I am being fed some information here. Of those who completed our most recent graduate survey, only less than 6% of GPs emigrated. There was a much higher number probably post 2011 up to 2017 but since then, the number has been falling. Covid-19 may have impacted on that as well but based on our recent data, the number of people emigrating is less than 6%.

Deputy Róisín Shortall

I imagine Covid-19 had a lot to do with that in the past couple of years.

Mr. Fintan Foy

It would but even before Covid-19, the number was beginning to fall.

Deputy Róisín Shortall

Okay. It is about asking people what they need to stay here.

Mr. Fintan Foy

We do that. We have graduate surveys and membership surveys and an awful lot of what is in this is based on that feedback.

Deputy Róisín Shortall

I am just thinking about the Dr. Niamh Humphries survey and the research into hospital doctors.

Mr. Fintan Foy

Yes.

Deputy Róisín Shortall

There needs to be an equivalent for general practice.

As can be gathered, the committee would be strongly supportive of what the ICGP is trying to do and we want to find out more about the strategic review group. We will definitely pursue it in correspondence with the Minister but will also, I hope, take this matter up directly in the new year. It was said there was a person in the Department who was dealing with the witnesses on all of this. What level is that person at?

Mr. Fintan Foy

To be honest, I do not know but he is a senior person. I cannot remember his exact title.

Deputy Róisín Shortall

Has Mr. Foy been given any indication of the timescale that will apply to the review?

Mr. Fintan Foy

No, not yet, other than to say it is high in the priority list.

Deputy Róisín Shortall

We have been told that recently and have concentrated a lot on workforce planning. There is no evidence that there is a team in the Department concentrating on this and that is what we would like to see.

Mr. Fintan Foy

Our sense is that it is imminent, yes.

Deputy Róisín Shortall

Okay. The other issue that was mentioned was shared GMS contracts and a suggestion about the need for those if somebody understandably wants a better work-life balance and is not committed.

Dr. Diarmuid Quinlan

Certainly some of my colleagues would say that taking on a full-time GMS contract with all the responsibilities that entails such as 24-7 cover is a substantial barrier for someone who due to their personal circumstances cannot provide that service.

It goes back to what the Deputy was saying about the GMS contract being 40 years old. Maybe it needs to be substantially reviewed in light of current workforce prices but also the changed demographics and the changed work-life balance people want. It is part of a bigger picture.

Deputy Róisín Shortall

Where are we with a possible review of that contract?

Dr. John Farrell

As the Deputy mentioned earlier, we leave those matters to the IMO. We are responsible for the training and education of doctors and their continuing professional development. With matters to do with contracts, we can start the conversation ourselves.

Deputy Róisín Shortall

It strikes me again that it is an issue of who is responsible. If a Minister can say they are all private practitioners and it is up to them to locate where they wish, that is a very good excuse for a Minister not taking responsibility for ensuring an adequate supply of GPs or other aspects of the service. That is why we need to consider the dual approach to this. If people want to continue with the existing contract, that is fine and we can recognise the contribution they make, but there is a need for a new model. That is undoubtedly the case. It is hoped we will be back to the ICGP some time in the new year-----

Dr. John Farrell

To make some progress.

Deputy Róisín Shortall

I am more than happy to support it very strongly.

Chairman

Following on from the question of the shared contract, would that work to try to encourage some of the GPs who are facing retirement? Would it be helpful?

Dr. Diarmuid Quinlan

We need to look at all options and, as Deputy Shortall said, to look as widely as we possibly can and do everything we can to recruit and retain people in our GP workforce.

Dr. John Farrell

We need to retain that 14% over 65 years, certainly in the short term, or we will be in terrible trouble.

Chairman

Again, we need supports around that. That is why I thought of the shared contract but maybe they would be reluctant to go down that route. There are hours and you are isolated in a rural area. For a GP it is very difficult.

Dr. Diarmuid Quinlan

The corporate knowledge that doctor brings to that community would be invaluable to a younger doctor starting in that area.

Deputy Colm Burke

The ICGP report published in October referred to the Scottish system in relation to medical students. We do not have a system here in Ireland where medical students work within GP practice for a period. They attend clinics in hospitals but I understand they are not in GP practices while they are going to college. Am I correct?

Dr. John Farrell

The undergraduate exposure to general practice is not what we would like.

Deputy Colm Burke

Has the college engaged with the universities?

Mr. Fintan Foy

We have.

Deputy Colm Burke

Does it believe it would be of assistance in trying to get more of those graduating into the GP system?

Mr. Fintan Foy

Absolutely. At the moment in most medical schools, GP time would be up to four weeks maximum. We would strongly recommend that 20% of the clinical curriculum would be dedicated to spending time within general practice. Obviously, funding is needed to enable the universities to do that.

Deputy Colm Burke

If that were put in place and an agreement reached on it, then the question would be the number of GP practices that would be prepared to come on board to facilitate that.

Mr. Fintan Foy

Yes.

Deputy Colm Burke

Would that be a challenge?

Mr. Fintan Foy

It is a bit like we said earlier. There are a number of challenges but I think, if the funding is there, that is a challenge that is achievable.

Deputy Colm Burke

In the past six years in Ireland, the number of people working in the hospital system has increased from 103,000 to more than 137,000 whole-time equivalents. That is an increase of over 33%. That has been achieved in a six-year time period. Can we reach the targets the ICGP is talking about on the basis it gets support from the Department of Health and the HSE right across the board?

Mr. Fintan Foy

If there is a commitment across the board, then yes.

Deputy Colm Burke

I return to the issue of postgraduates who go to college and have to pay full fees because they already have a university degree. I have had this argument with the Department of Finance over the past three to four years about how they cannot write that loan off against tax once they qualify. Has ICGP had any engagement with the Department of Finance on that? It is a challenge if someone is paying fees of €18,000 or €20,000 per annum over four years, which amounts to €80,000 plus accommodation.

Dr. John Farrell

Absolutely, but that is something that may come out of the strategic review, that there would be a recommendation of something that could be done. It would be relatively inexpensive in terms of overall Exchequer spending.

Deputy Colm Burke

That was my argument because, in real terms, we would be producing more doctors. If I borrow €100,000 to set up a business in the morning, I can write that €100,000 off against tax, but if I borrow €100,000 to go to college and I am providing a service when I qualify, and it is an essential service, I cannot write it off against tax.

Dr. Diarmuid Quinlan

That is a very good suggestion. We know that graduate-entry medical students are much more likely to specialise in general practice. In our document we call for innovative financial solutions. That is a very innovative financial solution whereby a graduate-entry medical student with a substantial student loan who goes to work in a rural area could offset their loans against tax. That would make it very attractive for people.

Deputy Colm Burke

Another problem for those students is that all the financial institutions are refusing to provide loans for those students, as I understand it. There is now a difficulty in their getting loans.

Mr. Fintan Foy

That was raised at a recent council meeting by one of the members. We are aware of that. We should be doing everything possible to enable this group of people to go into a fast-track four-year medical school programme of whom many will end up in general practice. If the banks are another obstacle, we are certainly not getting anywhere near that happening.

Deputy Colm Burke

The ICGP has not had any engagement with the banks on this issue at this stage?

Mr. Fintan Foy

No, not on-----

Deputy Colm Burke

But it believes it is something that needs to be dealt with.

Mr. Fintan Foy

Yes, it was raised about three weeks ago at our council meeting. It is something we will engage on.

Deputy Róisín Shortall

What is the percentage going into general practice at the moment from the graduate entry?

Mr. Fintan Foy

I do not have those figures.

Deputy Róisín Shortall

It is high.

Mr. Fintan Foy

It is quite high, yes. It is attractive for people to go into a four-year training programme, particularly if they have large debts they have incurred.

Dr. John Farrell

University of Limerick is the example. It has a higher proportion of its graduates going into general practice.

Deputy Róisín Shortall

I was just curious.

Deputy Bernard J. Durkan

I want to revisit the promised review. We all accept the need for it. However, the situation is very urgent and there could be a programme in the interim to address the salient issues so that the review would continue but these issues would be addressed as a matter of urgency. Is that a possibility?

Mr. Fintan Foy

In some ways we are better off looking at the whole problem rather than looking at problems in isolation. The point made by Deputy Shortall around workforce planning is critical. It is a critical part of the overall review. Our preference would be for the strategic review to start immediately or as soon as it can in the new year. We approach it from that perspective.

Deputy Bernard J. Durkan

I would be happy enough with that if we could rely on it being about to happen. What about in the event that it does not? Unfortunately, in this country we are more conversant with things that do not happen on time. In the event it does not happen on time and in line with requirements, would there not be some merit in identifying the most sensitive areas so that we do not leave areas with no or totally inadequate GP cover in the meantime and we would address them to some extent pending the outcome of the review?

Dr. Diarmuid Quinlan

That is a very good suggestion. I think we have outlined them clearly in both the submission and the Shaping the Future of General Practice documents. I would hope we would expedite the strategic review in the Department of Health, and I call for the committee's support on this, so that it would be very early in January 2023.

Chairman

I will bring the meeting to a close. The committee will follow up on that. We give that commitment. The engagement was very useful. It was illuminating on some of the issues raised.

It gives the committee a lot of food for thought as we move forward. We will certainly pursue this as a committee; the representatives have our commitment on that.

Deputy Colm Burke

Will it be possible to go back and see what progress has been made by the Department and the task force?

Chairman

From today, we can write to find out where it is at. We may engage with the ICGP afterwards about the link person, who will oversee this, in the Department.

Mr. Fintan Foy

I can provide that later.

Chairman

That would be useful. I thank representatives from the Irish College of General Practitioners for assisting the committee on this important matter. We will certainly keep this under review in the context of overall manpower planning in the health services. This concludes our last public meeting of 2022. I wish everyone - staff and members - a happy Christmas. My constituency colleague, Deputy Lahart, has been out sick with health problems and I wish him well and a speedy recovery. I hope you all enjoy the break. Nollaig shona daoibh go léir.

The joint committee adjourned at 12.21 p.m. sine die.