JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Wednesday, 28 Jan 2009

HSE and Department of Health and Children.

Chairman

This is the first in a series of public hearings to be conducted with a view to producing a report on the question of the primary health care strategy. The joint committee's intention is to lend focus and impetus, through its report, to the early and full implementation of the primary health care strategy. Members will now be addressed by representatives of the Health Service Executive and the Department of Health and Children. I welcome to the meeting Ms Laverne McGuinness and Mr. Brian Murphy from the Health Service Executive, and Mr. Jimmy Duggan and Ms Bernadette McDonald from the Department of Health and Children.

As usual before we begin, I draw attention to the fact that, while members of the committee have absolute privilege, the same does not extend to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

At the end of the presentation, members will ask the witnesses questions. I understand that the committee will be given a brief executive summary, given that we have already received and read with great interest the detailed submission put before us.

Mr. Jimmy Duggan

I thank the committee for the opportunity to make this presentation. On behalf of the Department, I would like to give a brief overview of the policy context in which the primary care developments are occurring. The starting point for many aspects was the primary care strategy, which was published in 2001 and outlined an approach that gave primary care a focus. It stated:

Primary care is an approach to care that includes a range of services designed to keep people well, from promotion of health and screening for disease to assessment, diagnosis, treatment and rehabilitation as well as personal social services. The services provide first-level contact that is fully accessible by self-referral and have a strong emphasis on working with communities and individuals to improve their health and social well-being.

The strategy also set out primary care's key aims, including "a greatly strengthened primary care system which will play a more central role as the first and ongoing point of contact for people with the health-care system", "an integrated, inter-disciplinary, high-quality, team-based and user-friendly set of services for the public" and "enhanced capacity for primary care to complement the existing diagnosis and treatment focus in the areas of prevention, early intervention, rehabilitation and personal social services".

The strategy went on to provide for the creation of primary care teams, outlining a number of key elements to underpin their operation. For example, they were to be patients' first point of contact, put patients at the centre of care, an element following on from what had been outlined in the overall health strategy published in 2001, deal with health problems at the lowest level of complexity, use a group of professionals in a team-based approach and cater for a population of between 3,000 and 7,000 people. While the latter point was the strategy's initial description, the HSE has come to the opinion that the relevant figure should be of the order of 8,000 through the evolution and consideration of practical issues. According to the strategy, primary care teams should meet 90% to 95% of their populations' health needs, which should be identified by way of locally conducted needs assessments.

The strategy outlined the series of actions necessary to drive implementation, including the establishment of a national primary care task force. According to the strategy, a number of locations in which to establish implementation projects were to be identified initially. In 2002, locations were picked in each of the ten health board areas. Those locations were Arklow, Ballymun, Cashel, Erris, the Liberties in south Dublin inner city, Lifford, Portarlington, Virginia, west County Kerry and Tipperary-Limerick.

The 2006 review of these initial projects made findings on how they had worked and what should be learned from them. It identified a number of issues, such as recruitment difficulties, which were compounded to an extent by shortages in some professional grades. Premises needed to be developed, with team members working from a single set of premises wherever possible. The importance of people operating from one set of premises has also been the HSE's experience. There was also a need to develop comprehensive population registers, which would be tied into the development of a unique personal health identifier. Through an effective communication process, awareness of the teams' existence and the services that they provided needed to be raised among local populations. The development of a national ICT system, which would have a crucial role to play, was necessary. Team-building also needed to be supported. A number of other issues were identified.

The review has informed the work of the HSE in terms of the strategy's implementation and development. The focus since has been on putting more primary care teams in place. I will hand over to Ms McGuinness.

Ms Laverne McGuinness

I thank the committee for the opportunity to brief it on our progress in transforming health and social care services, particularly in terms of the development of primary care services in local communities. Following my opening comments, I would welcome members' questions. With my colleagues, I will do my best to answer all of them.

In October 2006, we launched our transformation programme, at the heart of which is our overriding objective to provide the public with easier access to the right care in the right place at the appropriate time. We aim to provide up to 90% of the care ever needed by people within either their local communities or their homes. This approach is better for patients than the traditional approach where we relied too heavily on acute hospitals to provide care that could, with the right supports, have been provided locally. It will also enable us to free our acute hospitals to focus on delivering the types of specialist care that can only be provided therein. We aim to have both community and hospital services working hand in glove as a single integrated service and to make patient journeys for health services to be as seamless and free of delays as possible.

Central to this strategy are primary care teams, the building blocks for the new health service in which the emphasis is on building community-based teams. Primary care teams provide a one-stop approach and can meet or arrange the majority of care required by the public, be they general practitioner services, physiotherapy, public health nursing, diagnostics or so on. We plan to have a primary care team for every 8,000 people.

A typical team will consist of GPs, nurses, home helpers, physiotherapists and occupational therapists. All of the team's health care professionals will work together to develop individualised care plans for patients, particularly those with chronic illnesses and other complex needs. They will share information and their respective skills to ensure that patients with the greatest need receive services in a timely and co-ordinated way.

Depending on their needs, patients can be linked through their teams with the services of other primary care professionals, such as mental health services, specialist child care and disability services. If hospital care is necessary, links and arrangements can be made with local or specialist hospitals. This access to hospital services is an important feature of the teams, whether it entails access to specialist consultants or diagnostic services, such as X-rays or ultrasounds, and is a central tenet of our integrated system. The planning of admission to and discharge from hospitals is a strong feature of the new service, with strong links between hospitals and primary care teams. This integration between primary care and specialist services within the community will ensure that patients get timely admissions when required and do not spend unnecessary time in hospital.

From the point of view of patients, primary care teams provide them with local, identifiable and accountable entry points into the health and social care service. When they access a service, they should have the confidence to know that their further journeys should be seamless and free of delays.

Primary care teams are also involved in health promotion to improve the overall health of local populations and provide a range of services for patients with existing conditions, such as diabetes, respiratory disorders, cardiovascular ailments and depression, to name but a few.

Following an extensive planning exercise, we have identified that we need a total of 530 primary care teams. We plan to have all of them in place by 2011. By the end of last December, 93 teams were in place and their meetings with HSE clinical and therapy staff were attended by almost 300 GPs or their representatives. These meetings discuss patient cases and agree schedules of care. Our target for 2009 is to have 210 teams operating, representing 40% of our overall total of planned teams. We are on schedule to achieve the target.

Central to achieving our transformation objective is the need to arrange the way in which front line community staff work with primary care teams. An extensive exercise is currently under way to review and reconfigure the existing staff working across primary, community and continuing care with a view to meeting the staffing needs of the planned primary care teams and other specialist services. Where possible, primary care teams are based in a single facility to provide easy accessibility for patients and to enhance multidisciplinary teamwork. A programme to procure primary care centres to accommodate the emerging teams was initiated by the HSE in 2007. Approximately 200 are under consideration. We will be leasing the public health infrastructure elements, by way of a public private partnership initiative. This approach has yielded significant discounts on the open market prices. The infrastructure programme aims to have all sites identified by the middle of this year, with the first group of 80 to open by the end of 2010 and the full complement to open in the course of 2011. In addition to these developments, we are continuing to develop primary care centres funded through the HSE capital allocation programme. A number of these centres are at an advanced stage of development.

In addition to the core services provided by the primary care teams, such as GPs, public health nurses, many additional and modern ways of providing services have been developed. Most of the initiatives have been developed after involving patients and listening to their views on services. This type of patient involvement is a key component of our strategy to match services to patient needs.

For example, some of primary care teams in Skibbereen, Mizen and Dunmanway have wound assessment clinics. The primary care teams in Lifford and Castlefin, Donegal, have established a dedicated diabetic clinic for patients with type 2 diabetes. Specific diabetes procedures have been developed in Banagher and Kilcormac primary care teams. The Togher primary care team in Cork has developed a specific programme that links the primary care team with local palliative care services. Early pregnancy initiatives have been developed in the Ballymun primary care team. There are five cancer pilot programmes based in five primary care teams. Another example is the availability of X-ray services for GPs participating in the Arklow primary care team.

I am pleased to have had the opportunity to update members on the progress in the development of primary care service teams. We welcome any questions or issues that members would like us to address.

Deputy James Reilly

I thank Ms McGuinness and her team. I am familiar with Ms McGuinness as the director of the primary, community and continuing care division. Can Mr. Duggan tell us what is his role?

Mr. Jimmy Duggan

I am the principal officer in the primary care division in the Department of Health and Children. We have overall responsibility for policy on primary care.

Mr. Brian Murphy

I am the primary care services manager within the HSE and I report to Ms McGuinness.

Mr. Brian Gilroy

I am the national director of estates in the HSE.

Ms Bernadette McDonald

I am the assistant principal, working with Mr. Duggan.

Ms Laverne McGuinness

Dr. Joe Clarke is also present. He works as part of the primary care transformation team.

Deputy James Reilly

I know Dr. Clarke.

Deputy Caoimhghín Ó Caoláin

Deputy Reilly also knows Mr. Ray Mitchell.

Chairman

Now we have all been introduced, we can continue.

Deputy James Reilly

I fully subscribe to the principles outlined. Those of us working in primary care understand how much more can be done and how much more efficiently it can be done. Reports by Deloitte & Touche and Tussing and Wren show that the money available in GMS and primary care is still outstanding. The major surprise is that, even after all these years of different payment systems between private and public, public and private patients have a same-day service from GPs. General practice is not the entirety of primary care but the major issue is how we can achieve the goal. This began in 2001 and we are now in 2009.

While it is all very well to refer to teams, virtual teams and doctors attending and showing interest, the reality of additional services to patients is somewhat scattered. One need only look at the long list of examples given by Ms McGuinness, scattered across the country. There is no uniformity nor any impact in a general sense. Local initiatives are taken in and work well in some areas but not in others. Some would work well all over the country but the infrastructure is not in place. I tabled a parliamentary question on how many primary care contracts have been signed in respect of these teams and the answer was that one has been signed.

I consider chiropody, dental and dietetics as part of primary care. What initiatives does the HSE have to achieve a real roll-out of primary care services along the divisions outlined, to which I subscribe? I ask this in view of the fact that it has taken almost nine years to get to where we are, which is not very far from where we started, and in the context the current economic climate.

Deputy Jan O’Sullivan

I welcome the delegation from the HSE and the Department of Health and Children. We agreed that the strategy is good but people do not believe it will happen in the current climate. There is real concern that, while we do not build up services that are required, we are cutting back on services in the Teamwork report. I am familiar with this matter, being from the mid-west.

GPs in Clare and Tipperary rejected plans for a hospital reconfiguration unanimously on the basis that they do not believe that the primary care service will be built up in the current economic climate. The plan is to have all 530 teams in place by 2011. This involves purchasing premises in some cases. One aspect of this plan is that GPs will be required to pay for their offices within the purchased premises. Is the HSE going ahead with this on the basis that it will be given funding to put these teams in place? Is there a possibility that the HSE will build on what exists? For example, there may be a number of GP practices close to each other, where there could be a physiotherapist in one practice, a speech therapist in another and a dietician in another. Will the HSE stick with this plan rigidly in terms of having single facilities?

What will happen to current GPs who are happy where they are and do not want to buy into new facilities provided by the HSE? Have assurances been given with regard to the capital funding to purchase such premises? How will the severe cutbacks in funding to the HSE affect the plans and the timescale of 2011 to roll out all of the teams? How many full teams are in place in single facilities and how many are in place in multiple facilities? My overall concern is that this is a good idea but people do not believe it will happen because of the current economic climate and the history of what has happened in the north east in respect of hospital reconfiguration.

The primary care unit is the basic structure through which the majority of people should be able to access health services. Many people do so in the current system. Physiotherapists must emigrate because they cannot find jobs due to the severe cutbacks this year. Does the HSE realistically expect this holistic primary care network around the country to relieve the pressure on acute hospitals in the current economic climate?

Deputy Rory O’Hanlon

I thank Mr. Duggan and Ms McGuinness for giving us an overview of the situation. I will make only two points because I notice that the Chairman is looking at the clock.

The questions of uniformity and distribution must be addressed because the teams may not be up and running as quickly as one would like. I do not wish to be parochial but if all the teams were first built in the greater Dublin area, it would be a long time before the peripheral region of Cavan-Monaghan was reached. The level and availability of primary care services vary greatly at present.

I fully support the current strategy but the greater the number of services the more fragmented they become. A reporting mechanism will be necessary and, as the leader of the primary care team, the GP should be reported to in respect of his or her own patients. Not only in this country but also across the water, it appears that in many cases abuse was overlooked because the individual professionals, a multiplicity of whom could have visited a house, did not report directly at primary care level. Even though a professional from one discipline was aware that a serious issue had arisen, others were not made aware. Somebody on the primary care team needs to be responsible for co-ordinating such reports.

Deputy Margaret Conlon

I welcome the delegation. I share Deputy O'Hanlon's view that this is the way to proceed in terms of giving people access to services. However, questions arise in regard to whether the strategy will come to fruition given that the goalposts have been moved so many times. The north east offers evidence of that.

I am also concerned about the shortage of skilled professionals in certain disciplines. If primary care teams are to be successful in providing uniform services, how should that problem be addressed?

My next question on the level of co-operation with GPs may be somewhat parochial. In the north east, and particularly the area from which I come, there is serious resistance among GPs to the plan because while they see its importance they do not believe it will replace the need for acute medical care. How is it proposed to bring them on board? In regard to the north east, I have a difficulty with the fact that the transformation programme is not led by a clinician. If the GPs are not on board I do not know how the strategy can be progressed.

Consideration should be given to patient education from the positive perspective of health promotion. In some cases, people who present to their doctors may in fact be more suitably treated by a nurse or other primary care professional.

Senator Phil Prendergast

In regard to the primary care team models based on the multidisciplinary team, how will this relate to existing acute services? Who will be eligible to receive the service and how many advanced nurse practitioners are registered? What will be the role for clinical nurse specialists and advanced nurse practitioners?

Deputy Charlie O’Connor

As other colleagues have been parochial, I will mention Tallaght once. The town in which I live is the third largest population centre in the country. We have a first-class hospital which is always under pressure.

The concept of primary care teams should be strongly supported. As a Government Deputy, I have to express my fear that the strategy will fall down the list of priorities, regardless whether we are in good or challenging times. Deputy Reilly is more experienced in this area than I but I take the view that everything should be done to keep people out of hospital.

Deputy Caoimhghín Ó Caoláin

I join other members in welcoming Ms McGuinness and her colleagues from the HSE and the Department. It is generally acknowledged that we have a shortage of general practitioners. The average number is 52 GPs per 100,000 population whereas the comparable figures are 164 in France, 144 in Austria and 102 in Germany. How does the HSE expect to properly provide the number of GPs required for the roll-out of primary care centres when we have such a serious shortage already? What steps are being taken and what is proposed to ensure we have the complement of GPs required to undertake the full programme?

On Monday, the Minister of State at the Department of Health and Children, Deputy Moloney, specifically stated that community mental health teams would this year be operating alongside primary care personnel in 20 new primary care centres. He was speaking at a reaffirmation to the press of the commitment of the Government and the HSE to A Vision for Change. However, he also indicated the intention to move towards the closure of a number of main psychiatric facilities around the country. Are the representatives in a position to identify the 20 centres to which the Minister of State referred in his contribution?

I received a reply from the Minister for Health and Children to a parliamentary question I tabled on primary care centres which indicated they are now to be provided by the market through rental of floor space rather than from the capital programme as proposed in the NDP. Do the representatives not accept that we are strapping the health services into long-term commitments to landlords and expensive lease arrangements which may address short-term capital requirements but will offer no sense of permanency? As the period lengthens, we are going to see public funds going into the pockets of facility providers rather than into direct care provision, which is where I want to see the greatest investment.

Chairman

Am I correct in saying that we have only seen serious action in primary care since the end of 2006 and early 2007? I ask the representatives to clarify whether it will be essential to co-locate professional in these teams. In regard to the plan to have 530 teams in place by the end of 2011, will these be co-located? How many of the 210 teams planned to be in place by the end of 2009 will be in shared facilities?

In terms of the relationship between primary care and hospital services, will that involve referral beyond accident and emergency departments, which is often the case at present, to a hospital bed if admission is required?

Ms Laverne McGuinness

Some of the questions are similar so I will answer them in that vein. One question dealt with the timeframe. In 2008 we stated as part of our service plan that we would roll out and have in place 97 primary care teams. By the end of December we had 93 of those up and going and the four we did not have in place were implemented in January. By the end of January 113 of these full functionary teams will be in place. They are not all co-located in one centre but they are functioning as full primary care teams. They are holding multidisciplinary team meetings and providing core services around patients.

A question was asked by Deputy Reilly, as well as other Deputies and Senators, regarding fragmentation and the different types of services. I spoke about some wound management clinics, with diabetes services in some. In order to get a stimulus with the GPs, some GPs would have had a particular interest in developing diabetes or wound management clinics. That is not to say they are the only places which exist. There is a requirement for standardisation and innovation but we must get the balance right.

As part of the reporting as well as to gauge the effectiveness of these primary care teams, we are currently carrying out an evaluation with Population Health to measure the impact of primary care teams on our population and their effectiveness. We expect to have that completed by the end of April and we will report back to the committee on that.

There are two other important thrusts. One relates to capital infrastructure, how it is funded and whether there is an issue of funding not materialising. I will ask my colleague, Mr. Brian Gilroy, to speak on that as it will be provided through a public-private partnership initiative.

The other thrust relates to resources, such as the staff required for primary care teams. This is not all about new staff; we currently have staff and we could take social workers, child care workers or physiotherapists, for example, who work singly, and bring them together, which is what a primary care team is about. The outcomes would be better as a result, as international studies have proven. This is about reconfiguring staff to be mapped into primary care teams.

We have every street identified with regard to where those primary care teams are and we can make the list available to members. The list of the 93 teams currently up and running is also available, broken down by county and street, and this can be made available to members. We can make available the document outlining the numbers we propose to have rolled out by the end of the year. I will hand over to my colleague to deal with the capital question.

Chairman

On the question of principle, how important is that these teams be co-located in the overall plan?

Ms Laverne McGuinness

It is extremely important that they are approximate or near. Some teams are working very effectively, although they are not co-located. We can reference a couple of those in Arklow and Blanchardstown. Although they are not co-located, they still come together to have clinical team meetings. There is a better outcome if the teams are co-located, although this does not mean there only has to be one primary care team in a primary care centre. There may be three or four primary care teams clustered in a centre.

Chairman

Co-location is the ideal.

Ms Laverne McGuinness

Yes, but it is not the only way. We should draw that distinction.

Deputy James Reilly

How many are co-located now? At the outset I asked what specific initiative, if any, is in mind to make this happen in the current economic climate.

Deputy Jan O’Sullivan

Where do the current health centres fit in?

Mr. Brian Murphy

Under the current contractual arrangements with GPs, they are not obliged to move location into any of the proposed centres so we must work around that. There are clear challenges in procuring premises within a very short space of time. One can work very effectively through a team operating across a number of locations and communication is key to that.

There are approximately five or six currently working in one centre but I can clarify the number and get the list. It is logical that where people are working in one location or building, they have a better chance of engagement and interaction. Through conversation with GPs in particular, the biggest impression is the amount of work that can be done on a casual basis. By way of explanation, if I have time——

Deputy James Reilly

Time is running out but the witness has answered the question to my satisfaction. Will Mr. Murphy address the second question?

Mr. Brian Murphy

That asked what initiative we have to roll out the teams.

Deputy James Reilly

Yes.

Mr. Brian Murphy

We would not need much additional funding for the teams. As Ms McGuinness outlined, we are trying to reconfigure our existing primary, community and continuing care staff, and that process is currently under way. We are considering how they can fit into the teams. We have mapped out the 530 teams and we have an initial needs analysis for those teams, looking at the core staff. We are looking at where we can get the staff working in disciplines in other areas within PCCC to work within teams. For example, physiotherapists work in clusters and groups, as well as occupational therapists. We are breaking those down and assigning them to teams working with GPs, nurses and home help, and speech and language therapists. It is a work force planning exercise, in essence, to determine where those are going to come from.

That plan is in place and for the past two years we identified specific teams, with some teams developing quicker than others. Teams that we had not anticipated coming on board surpassed other teams. There may have been personality issues or matters related to geography and accommodation.

To answer Deputy O'Sullivan's query on existing health centres, much of the existing infrastructure is outdated and not fit for purpose for today's requirements. We acknowledge that and the programme of procuring the 200 premises will, I hope, address those deficits. Mr. Gilroy might speak on the estates issue and what we do with those health centres. Currently we are maximising the use of the resources we have in trying to get people to work in teams, although the challenges of being in different locations still persist.

Deputy James Reilly

To clarify, no new resources are required and it is hoped to work within existing staff. I will leave the building question to Mr. Gilroy.

Ms Laverne McGuinness

When the strategy was initially announced, it was stated that additional resources would be required. In 2009 there are some additional resources coming into the primary care teams but the primary thrust is to reconfigure all the staff we currently have into primary care teams. It is the financial reality that we must reconfigure staff into primary care teams. There is no new resource to be introduced.

Chairman

Did Mr. Gilroy want to comment on the property acquisition aspects?

Mr. Brian Gilroy

I will provide a quick outline of the process to give an understanding to the Deputies of what we did. I am responsible for the capital programme in the HSE and we looked at the programme approximately two years ago. At that stage we assessed the value for money being achieved in primary care, and in some locations we were building primary care centres without being able to get GP involvement. That creates a problem.

We developed this scheme, which is primarily property-based, and we advertised to the market a series of locations in December 2007 and another list in early 2008. These asked for expressions of interests from people who were building or planning to build primary care centres. The thrust behind this is that independently of what we were doing, many GPs around the country were starting to build their own practice centres with or without us. There was a growing interest in the market.

We took the first tranche of approximately 20 from the advertising campaign to our board and got approval at that level. We built a cost-benefit analysis on the initial pilot. We have run that cost-benefit analysis with the NDFA up to the point of the budget in October, and the Minister for Finance and the Minister for Health and Children endorsed the strategy. We have a shadow-pricing model built with the NDFA and we revisit that value-for-money assumption quarterly as we roll out the programme.

With regard to level of commitment, at this point we have over 90 approved by the HSE board. Of those, 35 are now in contractual obligations. I do not know the date of the parliamentary question put down by the Deputy.

Deputy James Reilly

It was about a week ago.

Mr. Brian Gilroy

At this point there are 35 in contractual obligation.

Deputy James Reilly

Can we have clear language? Are the contracts signed?

Mr. Brian Gilroy

Yes. Well, the process is that until the door opens we actually do not sign the lease, but at this point in a scheme that is not built yet we would be signing a commitment to lease. On the basis that the building——

Deputy James Reilly

How many commitments to lease have been signed?

Mr. Brian Gilroy

There are 35. At this point there are ten in the scheme that will open this year, of which two have not actually reached commitment to lease stage. There are existing buildings where GPs are operating and we are concluding negotiations with them. That is the timeframe. It is important to note — to address the concern about value for money for the State — that we ran the cost benefit analysis over a number of scenarios — doing nothing, staying in our health centres, buying the health centres and trying to get next to GPs, buying and staying separate from GPs, and this scheme. In all scenarios that we explored at the time — this is dated September of last year — there was a 30% drop in construction costs, and we considered moving to a discount rate of 3%. As it turns out, the discount rate has gone up. We use a value of 4.6% in the model, with stress testing. It has actually gone up, reinforcing the value for money.

The other benefit to the State of this approach is that it basically funds itself. It is cost neutral to the State for a period of about four years. Over the next 18 months to two years — to the end of 2010 — many of the buildings are being built, so we are not actually incurring the cost of them at that point, and from then on, we will be releasing a lot of small leases. If we take the typical provincial town where we have a number of premises dotted around — the physiotherapists in one location and others elsewhere — we get to release those leases. Coupled with that — we had a question earlier about health centres — we also get to sell the health centres. Between all of this, the entire programme is self-funded, and there is no cost to the Exchequer for a further two years.

Deputy Jan O’Sullivan

Could Mr. Gilroy clarify that? Is he saying it is to sell publicly-owned buildings and lease privately?

Mr. Brian Gilroy

Yes.

Deputy Jan O’Sullivan

Will that not be more costly in the long term?

Mr. Brian Gilroy

No, it is not. The cost benefit analysis was run over 25 years and it included the residual values at the end of the 25 years. We ran the process with the NDFA before we rolled the scheme out. That is the way the figures stack. We can make the cost benefit analysis available to people over time. As I said, we go back to that quarterly with the NDFA running our shadow pricing. We must bear in mind that many of the health centres are much smaller than the facilities we are going into.

Deputy Jan O’Sullivan

In effect, it is privatising the buildings. What were publicly owned premises will now be sold off and the State will be leasing privately from developers.

Mr. Brian Gilroy

From developers or GPs, yes.

Deputy Jan O’Sullivan

That is not a policy I agree with.

Deputy Caoimhghín Ó Caoláin

I am not comfortable with it. Could I just ask——

Chairman

We will be in a position to make our comments at a later stage.

Deputy Caoimhghín Ó Caoláin

Mr. Gilroy indicated he would share the cost benefit assessment.

Mr. Brian Gilroy

The cost benefit analysis, yes.

Deputy Caoimhghín Ó Caoláin

As Ms McGuinness has already indicated she will share other material from earlier, will he forward that information to members?

Mr. Brian Gilroy

Yes.

Senator Phil Prendergast

Could I have an answer to the question of how many advanced nurse practitioners are involved in those primary care teams that are already in place?

Mr. Brian Gilroy

The development of the advanced practitioner role has been focused on secondary care services, but in the context of developing our primary care teams, we do see a role for advanced nurse practitioners, working with the GPs in the teams and across specialist areas. Currently, however, we do not have a focus on that. Members will appreciate that we are in a stage of development and the role of advanced nurse practitioner must be placed within that context. The focus of the roll-out of the advanced nurse practitioners has been primarily in the hospital sector. We have one in mental health services, but not in primary care teams.

Deputy Caoimhghín Ó Caoláin

I mentioned the issue of GP provision and the 20 new primary care centres to which the Minister of State, Deputy Moloney, referred last Monday.

Chairman

Very briefly, as we are running badly over time.

Ms Laverne McGuinness

In relation to the shortfall of GPs to which the Deputy has alluded——

Dr. Joe Clarke

I am a GP. There is no doubt we have a GP manpower crisis. The age profile of GPs is in the 50s to 60s generally. We are training 120 GPs per year in a four-year training scheme, and we are developing with the Irish College of General Practitioners a phase 2 training programme, which will be an accelerated training programme of two years in general practice to cater for doctors who have already done their hospital training. This is at an advanced stage. At the moment it is a four-year course or nothing, while the phase 2 training will be over a two-year period. In addition, the Irish College of General Practitioners is launching an advertisement next week seeking expressions of interest in an advanced accelerated programme for GPs who are already out there in the community working as locums but have never gone through training schemes, and we are working with the college to fast-track these GPs through a programme whereby they will be available for application for GMS lists. We have initiated a GP recruitment campaign in the UK, in which we are advertising for GP graduates, and we are also working on part-time and family-friendly contracts, initially on a pilot basis, and also in the context of the new GMS contract.

Chairman

Would Dr. Clarke like to comment briefly on the mental health issue raised by Deputy Ó Caoláin?

Ms Laverne McGuinness

I will comment, if that is all right. Currently, there are community mental health nurses in some of the primary care teams. What is being proposed — it is only a proposal at this stage — is that for some of the primary care centres that have been identified, it may be possible to consider the provision of an additional space for community mental health day services. However, that is a proposal that has yet to go to the board. A number of centres have been identified as potentially suitable.

With regard to Deputy O'Sullivan's question about whether we are currently selling off our primary care centres, we actually do not have 530 primary care centres. Many of our health centres are very small, perhaps with just one or two rooms. Some of them are in a bad state of repair. It is not that there are 530 currently available.

Deputy Jan O’Sullivan

But there are still quite a few relatively new ones.

Ms Laverne McGuinness

They would not necessarily be sold off. Only 200 primary care centres are currently being procured. Some of these which are new and fit for purpose are currently being used. Thus, we are talking about many centres that are not suitable for the purpose.

Chairman

I suspect that as this process goes on we will have other questions and we would be grateful if we could communicate with the witnesses and get written responses which will help us in compiling our report. We have gone badly over time; we should perhaps have allocated more time to the witnesses. I thank them for being so succinct. It is clear that considerable energy and expertise is now being invested in this process. I compliment them on the work they are doing in this area.

Deputy James Reilly

I subscribe to that and encourage the board to consider the Chairman's suggestion. Of all the specialties, psychiatry is the most eminently suitable for placement in the community.

Sitting suspended at 10.50 a.m. and resumed at 10.55 a.m.