JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 29 Jan 2009

Irish Medical Organisation.

Chairman

I welcome Dr. Martin Daly, Dr. Paula Gilvarry, Dr. Peter Nolan, Dr. Johanna Joyce Cooney, Dr. Clare O'Sullivan and Mr. Finbarr Murphy and thank them for coming to help us with our deliberations on primary health care. Before we begin, I draw the witnesses' attention to the fact that while members of the committee have absolute privilege this same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against any person outside the House or an official, either by name or in such a way as to make him or her identifiable.

We are grateful to the witnesses for the paper they have supplied to us. We hope they will give us a brief synopsis of that and we will then have a round of questioning from the members. I hope we can do our business in 30 to 35 minutes.

Dr. Paula Gilvarry

We appreciate the opportunity to present to the committee. We are community medical doctors and members of the community medical committee of the Irish Medical Organisation. My colleagues are Dr. Peter Nolan, Dr. Johanna Joyce Cooney and Dr. Clare O'Sullivan, all of whom are community medical doctors, Dr. Martin Daly, who is a general practitioner, and Mr. Finbarr Murphy, who is the director of industrial relations with the Irish Medical Organisation.

Community health medicine is an area which delivers a range of front-line clinical preventative medical services to many individuals such as children, adolescents, older people, persons with disabilities and marginalised groups. All of our services are statutorily based and they are all free at the point of delivery.

The doctors are employed directly by the Health Service Executive, so we are independent medical officers for the HSE. We have qualifications across a broad range of specialties, all of which are listed for the committee, including everything from community health and public health and on to health economics and education. The majority of us have been in post for more than ten years, so we bring a wealth of knowledge to those posts. During that time, we have developed a detailed knowledge of the health needs of our local areas. We have also developed strong links with colleagues within the HSE and with other health and social care organisations with regard to everything from housing and education right through to non-governmental organisations.

We deliver a huge range of screening and preventative services. Some of these services complement the work done by GP colleagues, while others are more specialised and are not readily available in general practice. In our clinical role, one of the areas is the screening of children for disabilities that require early intervention and behavioural problems. We deliver BCG vaccines to infants and undertake an extensive programme of vaccinations in schools, where mass vaccination has proved to have a very high uptake and is cost effective. We would be a critical component of the HSE response to pandemic flu or other similar events.

We work in multidisciplinary teams in areas such as planning for older people and inspection of nursing homes. We have an impartial medical assessment role. We give advice to the HSE on eligibility for a broad range of statutory entitlements such as the motorised transport grant, mobility allowance, domiciliary care allowance and all the allowances available through the HSE.

We are not unique but we pride ourselves on having both clinical and management skills as part of our work. We all carry out a clinical commitment, so we are delivering front-line services but we are also managing and co-ordinating services to individual groups. Our participation in multidisciplinary delivery ensures service users get the best possible care in the right place at the right time.

We bring a broad overview of services in our local health areas, so we are facilitating effective delivery and co-ordination of programmes, such as health screening, to large populations. Effective health screening requires a critical population mass. We would screen hundreds of children every year for developmental problems. That critical mass makes us the experts in this area. We have shown over the years that we are good value for money and that we have an ability to maximise the uptake of immunisations. Many of the areas where we work would have an uptake of greater than 95% for everything from neonatal BCG to the 2-in-1 vaccine delivered in secondary schools.

Our specialist skills and experience would ensure we would be appropriately placed within the new managed care networks which will feed into the primary care teams. We would provide specialised clinical services to the multidisciplinary teams and we would liaise with secondary and tertiary services, which we already do and would like to develop. We would prefer that all services communicate effectively with the service user and with each other, and that our skills would be used to help share information, as appropriate, avoid duplication and ensure the patient's journey is as simple as possible.

In future, we want to see ongoing reorientation of the services in keeping with the principles of the transformation programme which is underpinning the primary care roll-out. We have a history of working at the front line with senior management as individuals and in forums, and we are well placed to participate in clinical governance, that is, in continually improving the quality of services, safeguarding high standards of care and working in an environment where clinical care will flourish. We see ourselves participating in the delivery of school-based programmes such as the cervical cancer vaccine and the measles eradication programme.

Our message to the Oireachtas is that we would ask the committee to acknowledge and support the clinical role of the community health medical service in primary care teams and networks. I thank the committee for its time and attention and would welcome any questions.

Deputy James Reilly

I welcome the Irish Medical Organisation representatives and thank them for taking the time to give us their view from a community medicine perspective of where they would like to see primary care going. I will revert to that issue shortly.

The BCG vaccine, with which there are currently many problems, was referred to. For the information of the committee, will the IMO give an outline of how important the BCG vaccine is and what the incidence of tuberculosis might be at present? There is a problem in that it is not available and, therefore, children and babies are being exposed to the risk of TB, which, as I understand it, is still very much a serious illness in our communities.

The IMO is involved in the inspection of private nursing homes. How does it see its future role in how the Health Service Executive's nursing homes will be inspected, given that we do not like the principle of the HSE investigating or inspecting itself? We do not believe it is sufficiently transparent and would like to know the plans in that regard. On the same issue, how does the IMO view its role in the Health Information and Quality Authority? Will it interact with the HIQA or will that involve a different set of doctors?

With regard to the IMO's special skills, what direction will effective child screening take in the future given that our population is increasing and there is only a small number of community medicine doctors, as I understand it? How do the witnesses see this panning out if we introduce an age-appropriate annual check-up for all citizens? I am not suggesting such a check-up would be annual. It might be a nine-month check, a five-year check or otherwise. The system is very disorganised at present. In some cases, general practitioners do it whereas in other cases it is done through the community health system. I would like to hear how the IMO would co-ordinate this and whether the witnesses would see the system co-ordinated through general practice or in some other way.

Where would the community medical doctors see themselves in regard to the primary care teams? I presume they would see themselves more in the primary care network rather than as part of the team. What sort of population do they feel is appropriate for each community medicine doctor to be responsible for to provide maximum effectiveness, given that GPs and dentists are generally responsible for 2,000 people? Looking towards the future of primary care, what single most important change would the delegates recommend, given current economic limitations?

Deputy Jan O’Sullivan

I welcome the delegates. Delegates from the Irish Dental Association referred to a serious shortage of personnel in the public service. Is this also an issue for the delegates from the community medical committee?

Following on from Deputy Reilly's question about networks versus teams, the committee is seeking clarity in regard to what is appropriate for a network and a team, respectively. Obviously, the delegates have the advantage in that they have direct contact with their GP colleagues within the Irish Medical Organisation. However, in terms of the role of community doctors specifically, will the delegates say whether the Health Service Executive consulted them in regard to the setting up of what seems to be their primary focus, namely, teams rather than networks? Do the delegates see themselves mainly as linking with a network rather than a team at the lower level?

We are all seriously concerned about the decision not to roll out the human papillomavirus, HPV, vaccination programme in accordance with the original timeframe of September 2009. There is some debate about how much the programme will cost. The delegates have suggested it could be delivered as part of the school-based programmes. Is any other vaccination programme delivered to the same age cohort and, if so, is there room for savings in terms of the cost of delivering the HPV vaccination programme? We are all anxious that it be introduced as soon as possible as an important element in preventing cervical cancer.

The delegates referred to having a role in maintaining standards of home care. I understand this relates specifically to elderly people and those with disabilities. There is a concern that a shortage of money is making it more difficult to ensure people receive the care appropriate to their needs. The optimum would be for people to remain in their own homes if at all possible rather than moving to a nursing home or other long-term care setting. Will the delegates respond as to how community doctors might ensure more people will be able to access whatever supports they require in order to stay in their own homes?

Deputy Rory O’Hanlon

I thank the delegates for their presentation and the documentation they submitted in advance. I recognise the important role they play in the delivery of health care and preventive health services. What we are discussing is the development of primary care teams. We want to have a state-of-the-art service. Where do the delegates see their role as an integrated part of a primary care team? It seems that in some parts of the State their discipline works in parallel with the GP service and that there is not the degree of integration we would like to see. I declare an interest in that I was a GP in a former life. It is important that GPs should be well briefed in terms of everything happening with their patients in their practices.

On prevention, the delegates have listed several skills they possess, which I have no difficulty in accepting. However, responsibility for prevention is spread among many agencies, some of which are outside the health service. They include agencies dealing with such issues as the use of tobacco products, the abuse of drugs and alcohol and road safety. What role do the delegates play in this regard and do they have an integrated approach with other agencies?

Senator Frances Fitzgerald

I thank the delegates for their presentation. What impact is the pressure on local health centres having on their work? The shortage of staff, particularly the failure to replace key staff and those on maternity leave, makes it difficult for remaining staff to do their job, whether it is the public health nurse going out to change dressings or speech therapist struggling to deal with long waiting lists. I am aware of a clinic which is allocated the equivalent of half a speech therapist where previously it had two. I assume health centres refer to the delegates and that there is a liaison between the two. How much is the pressure from the centres affecting the delegates' work? What is current capacity in terms of the assessments the delegates undertake, whether for domiciliary care allowance or other services, and to what extent are there waiting lists?

Chairman

Deputy O'Connor will now give us the view from Tallaght.

Deputy Charlie O’Connor

Who told the Chairman I am from Tallaght? The delegates may not have known this, but it is true that I often talk about Tallaght. I always say I bring to politics and certainly this committee my own experiences. I have found these sessions interesting and have been able to draw on what I know about Tallaght, the third largest population centre in the country. We have a first class hospital which was opened 11 years ago. I often emphasise that as a member of the planning board, I had a clear view that the hospital should deal not only with accident and emergency cases and the very ill but also with health promotion issues within communities.

It struck me while listening to the earlier presentations, particularly that of the Irish Pharmacy Union, that the buzz word of the week, straight from the Taoiseach's mouth, was "teamwork". I do not mean to be flippant in saying this. It strikes me that it is vital to have joined-up thinking so far as the delivery of primary care services is concerned. I have many conversations with GPs in Tallaght. Some of the delegates will know Dr. Tom O'Dowd, the Trinity College man who has made a strong case for such community medicine programmes and community endeavour. The Mary Mercer health centre in Jobstown is located in what might be described as a disadvantaged area. Other delegates spoke about health centres delivering an important service. This facility could stand anywhere in the State. It is the way primary health care services should be delivered and I am anxious that it continue.

Other colleagues have referred to the need for a teamwork approach. We get the impression listening to some of the delegations that management in the Health Service Executive never takes the opportunity to talk to people. I do not understand this. Why, if it seeks to deliver a first class service in any community — Tallaght is no different in that regard — does it not get people around the table who can deliver the services required by communities? I hope the work we have done in the last two days will facilitate such an approach.

Deputy Paul Connaughton

I welcome the delegation, particularly its president, Dr. Daly, who is my neighbour. In the delegates' professional view, if the primary health care scheme were operating effectively at local level, how many patients would we keep out of hospital? I accept it is impossible to quantify the numbers precisely but will the delegates give us some range? I have been listening for ten or 15 years to talk of how important this issue is. I refer to being able to ensure fewer people are obliged to attend accident and emergency units and so on. I seek an overview of the extent to which the witnesses consider that such a programme can be done locally.

Senator Liam Twomey

At issue is the role public health doctors fill in the community and as a general practitioner, I understand where the system works well. It works well in respect of many of the issues mentioned by the witnesses, such as vaccinations and overall population health. However, I wish to discuss areas in which it does not work or in which potential problems may crop up in future. Public health doctors always have inspected nursing homes and as the witnesses are aware, this joint committee in recent years has engaged in many discussions in which serious concerns were raised about a number of nursing homes. Obviously, inspection reports exist which would have been signed off by Health Service Executive staff, including public health doctors. There is a concern that public health doctors missed what was going on or perhaps came under pressure from officials higher up the line to ignore matters or to not raise issues.

A change in society is under way at present, in which more older people are being left at home, and both public health nurses and public health doctors will take on an increased role in this regard. General practitioners cannot really be expected to monitor it all as they may not see the people. Although concerns have been raised in respect of institutionalised care in recent years, the potential for such events to happen and not to be picked up on within the community is even greater. Have such concerns been raised within the medical profession outside of the witnesses' job as employees of the State? Have the witnesses put in place systems to act as doctors, as opposed to employees of the State?

Chairman

Can the witnesses give the joint committee the benefit of their experience or opinion on the issue of co-location? People have taken diverse views on what is forthcoming from the Health Service Executive in terms of its implementation of the strategy. Some people consider that the HSE is overly focused on buildings. My sense is that the HSE is highly focused on teams and we may be quite far from the point of providing the buildings it perceives to be the ideal place from which teams would operate. The witnesses should give members the benefit of their advice in this regard.

The view also appears to be emerging that a primary health care team to a great extent will be a local health promotion team. Do the witnesses subscribe to that view? For example, in the realm of immunisation programmes, how do they see the primary care team maximising participation in such programmes? As for the Irish Medical Organisation's position on the current shortage of general practitioners, what does Dr. Daly believe the IMO, the HSE or the Department of Health and Children should do about this problem?

Dr. Peter Nolan

Deputy Reilly asked about BCG, which is a vaccine to prevent tuberculosis and tuberculosis meningitis in particular. We deliver this programme to all newborn babies in Ireland and to unvaccinated schoolchildren. This vaccine still is recommended by most health authorities globally.

Deputy James Reilly

There have been serious shortages of the vaccine as well as long delays before children have received it. People have been obliged to wait for months before getting it. They then have been obliged to undergo a Mantoux test or a similar test to check they have not contracted tuberculosis already. What is the current risk of tuberculosis if children do not receive the BCG? Has the incidence of tuberculosis risen, remained the same or fallen in the past five years?

Dr. Peter Nolan

While it is increasing worldwide, in Ireland is has remained roughly steady. However it always is present in the background and we must remain vigilant against tuberculosis. It is still advised that all newborn children and unvaccinated schoolchildren should get the BCG vaccine. Both the national immunisation office and our health protection surveillance centre still recommend that we deliver that programme.

Dr. Johanna Joyce Cooney

The problem last year was a specific problem that was outside our control in that a problem arose with the supply of BCG vaccine. As we only have a single supplier, for a few months we did not have a BCG vaccine to deliver. While the issue of the Mantoux test arose for the older babies aged over three months, as a group of doctors we did our best to minimise it.

Deputy James Reilly

This is not a criticism of community doctors. I am trying to ascertain that there is a real risk of tuberculosis in Ireland, that children need to be protected and that getting the BCG is highly important.

Dr. Johanna Joyce Cooney

It is. I also wish to point out that although we are public health doctors, we operate within the community and thus do not have responsibility for infectious disease surveillance. There may be some confusion in this regard as Senator Twomey made a point about public health doctors. However, we are not directly involved in infectious disease follow-up or contact tracing as our public health colleagues do that.

There are areas in Ireland in which neonatal BCG is not delivered, such as the west, in particular. While there have been many reasons for this, the neonatal BCG programme in County Mayo will be ready to go from February onwards and resources have been made available. This is one of our priorities.

Deputy James Reilly

However, it is fair to state that some three-month old or four-month old neonates have not received the BCG.

Dr. Johanna Joyce Cooney

Yes.

Dr. Paula Gilvarry

In the areas in which BCG could not be delivered and in which an effort was being made to get the programme up and running, it always was the case that those children who could be most at risk were prioritised. In other words, I refer to those children who came from areas in which there was a high incidence of tuberculosis or for whom there was a family history of tuberculosis. A screening programme existed in which children at risk were considered. The biggest protection provided by the neonatal BCG is against TB meningitis. While I understand the BCG vaccine offers protection of 80% or less against tuberculosis, it is highly effective for TB meningitis. The other point is that the BCG vaccine is but one aspect of TB prevention and one still must be highly conscious of having a TB treatment programme, as well as robust screening and contact tracing programmes. We are highly anxious that such a programme should remain in place, together with the neonatal BCG programme.

Chairman

We will move on to the issues more pertinent to the primary care strategy.

Deputy James Reilly

I beg the Chair's indulgence but as I will be obliged to leave the meeting in about two minutes' time to conduct a radio interview, is it possible to get the responses to the questions I asked on the nursing home inspectorate, the Health Information and Quality Authority and the single item the witnesses consider to be most important in respect of the primary care strategy?

Chairman

Very well. Who will respond to those questions?

Dr. Peter Nolan

It always has been envisaged that the inspection of nursing homes will go to the HIQA although the date is uncertain at present. It may be July 2009 but that has not been confirmed yet. As complaints still will remain within the Health Service Executive, area medical officers will continue to have a role in the investigation of complaints. This will constitute a kind of monitoring mechanism because by the investigation of complaints, one often discovers what kind of care is being given in a nursing home. Sometimes a complaint gives one more information about the standards of nursing, care of the elderly people in the home, etc. than does actual inspection.

Deputy James Reilly

And on the most important matter?

Dr. Peter Nolan

I reassure the Deputy that we still will have a role in that regard.

Dr. Paula Gilvarry

I wish to make a point because I believe I am the only person present who actually conducts such inspections. My concern is that after we hand over the inspections to the HIQA, it then will be its responsibility to ensure its inspection process is robust. It will perform inspections on private and public facilities. It appears the complaints will remain with us and, as Dr. Nolan noted, a complaint can be an extremely useful tool. Although one might not act on it at the time, it goes into the report and if it is not of an urgent nature, it will be followed up at the next inspection or there will be a process of ensuring it stays live until the matter is fully investigated. However, this again goes back to teamwork, we have not been given a formal method of communicating with the HIQA about such complaints and this is vital. Last year, a social worker who deals with elder abuse contacted me to ask how we would tell the HIQA about such complaints, how would we ensure they reached the correct person and how would we ensure they were dealt with. It is important that, once the nursing home inspection process leaves us and irrespective of who deals with complaints, there should be a clear path to HIQA so as to ensure that important information is not lost.

Deputy James Reilly

What about the most important matter?

Deputy Jan O’Sullivan

Since we will address it later, we can put the question then.

Chairman

What is No. 1 on the IMO's wish list?

Dr. Peter Nolan

In times of economic necessity, the most important health care intervention is prevention. Second to clean drinking water, vaccination is the second most cost-effective health care intervention available. We have shown our ability to deliver newborn programmes for BCG and school vaccination programmes.

In times of economic necessity, all experts recommend that resources be concentrated on child health. Some studies have shown that, in the medium and long-term, the cost-benefit ratio may be as much as €7 in cost savings for every €1 spent on child health and children and family services. We have always prioritised children's health and vaccinations and will continue to do so.

Deputy James Reilly

Will Dr. Daly comment on general practice, given the fact that he is the only general practitioner seen by the committee so far?

Dr. Martin Daly

I thank the Deputy for the question, the answer to which I might integrate with my response to Deputies Connaughton and O'Connor. The IMO is aware that a manpower issue is looming. A generation of GPs who entered the General Medical Services, GMS, in 1972 are due to retire within the next five to seven years. I want to debunk the theory that the IMO has been opposed to the opening up of the GMS and complicit in the suppression of lists. Since May, we have had an agreement with the Secretary General of the Department of Health and Children and the chief executive officer of the HSE to carry out an in-depth audit of manpower needs in general practices in a structured manner.

It is important to point out that the Department's policy has been to reduce the numbers involved in the GMS. Since 1989, the Department has been of the opinion that it does not want many small GMS panels, since they are expensive to service and do not help with the delivery of services using a teamwork approach. While we agree in this regard, there should be a structured management of the opening up of the GMS.

Last week, we met the HSE's national managers. They discussed deregulating the GMS, carrying out mapping exercises in a remote office and picking a magic list of 12 black spots around the country where there were no GPs. According to our national GP committee meeting last night, lists are being suppressed by the HSE around the country. While I will not name the areas on the list, I will happily inform members in private. Where an existing panel holder in a provincial town had a list of 1,200 GMS patients, a new viable list of 400 GMS patients was advertised without consultation with the IMO. An interview panel was set up. No female practitioner held a medical card listing in the town in question. A number of people were interviewed, including two well qualified, young, female GPs, one of whom had been a principal in a general practice but had retired for a short time for family reasons. However, that list of 400 was given to the single-handed practitioner who had the 1,200-patient list.

We are annoyed and angered. Despite making it clear that we want more GPs, particularly younger ones, to be brought into the system in a structured way so as not to destabilise it and to allow the management of GP numbers, we meet national managers of the HSE and they tell the media that the IMO is suppressing lists. This is an untruth. I have given a specific example, but there are other examples of viable lists being suppressed in the past 12 months in the north east and some urban areas. This has been done at the behest of local HSE management to reduce costs and for managers' convenience, as they would not need to support a new practice starting up. It does not help the situation.

While manpower is an issue, we should not panic. Within the current framework of interviews and appointments, much can be done in co-operation with the IMO to alleviate many of the stresses. Last May, we committed to this process, but are still seeking a meeting with the Department and the HSE to progress the matter. We know that there is a crisis and everyone around us is discussing it, but the Department and the HSE have not seen fit to progress it in spite of an agreement with the Secretary General, the CEO of the HSE, who was also present at the meeting in question, and the CEO and president of the IMO. I want to make this clear.

We oppose the complete deregulation of the GMS, as any young doctors would set up in non-viable situations. We had a bitter experience in the 1980s when many young doctors were unsupported, worked from converted garages at the side of their houses and had no nursing or secretarial support. A similar situation will not address what the State and citizens need from GPs.

We welcome the HSE's initiative to ring-fence €200 million to lease primary care buildings in which GPs can operate to facilitate the roll-out of the primary care strategy. We have encouraged our members to become involved and have advised them to take the best legal estates, accounting and business planning so as to make the centres sustainable. The last thing we want is for people committing to the building of premises and discovering in four or five years, after the State, GPs and perhaps developers have made a considerable investment, that the model is not sustainable. It is important that the initiative start on a sound footing. We are heartened by the national estates manager, Mr. Brian Gilroy, who seems to have taken a pragmatic approach. We understand that, in times of economic stringency, funds are limited, but this important initiative should be followed through because of its importance.

Deputies O'Connor and Connaughton asked how many people can be kept out of hospital. GPs working in isolation cannot keep one extra person out of hospital, but GPs in teams and who are enabled to carry out a greater breadth and depth of service in the community can. Everything from the management of chronic inflammatory diseases, infusion services and haemochromatosis to warfarin services can be carried out in the community, but GPs in the current model are often doing so at a cost to their practices and themselves if they are committed to the services. Money does not follow the patient to the community.

No one would expect hospital consultants to provide a service in isolation. Rather, they have teams of nurses, allied health professionals and administrators to help. However, GPs are expected to provide a service at a moment's notice. If there is an influenza epidemic, one sees one's GP. One rings a GP the next morning if one has a breast cancer scare. There is no recognition of the fact that 100,000 consultations occur everyday in general practice with little complaint. There are few complaints because general practice provides equal access to public and private patients, a valuable element in the current GMS contract that should be kept.

The IMO did not agree with the hospital co-location policy. After being told by the Minister that it was the only show in town, we decided that we may have to——

Chairman

When we mentioned co-location, we meant the co-location of primary care providers at local level and in a single centre as distinct from what some members of the HSE might have discussed, namely, a communication network in a local area.

Dr. Martin Daly

I will say a few words in that respect, then finish. I referred to buildings, but they are not the only issue. Access to GP services has been a strength of the general practice system. I ask the Chairman and the committee not to forget that the strength of the current contract in general practice is that it has delivered high quality professionals throughout the country. Patients who access the service in west Cork will receive a service of broadly similar quality as patients who access it in County Kildare, Dublin 4 or east Galway. We must remember that, if we go into a centre, access to services is maintained. Centralisation and working in teams are important.

Chairman

I invite Dr. O'Sullivan or Mr. Murphy to address the questions raised.

Dr. Clare O’Sullivan

Every network, the provision of specialised services by several teams, is broader than a team. Our understanding of the concept is under development. I may say something different in a year's time but the idea is that several teams can provide the services of a network which is more specialised. The network may be confined to four primary care teams, or all the teams in the local health office area or across the region, depending on the level of specialisation. We see our role as being complementary to that of GPs as community health doctors. We apply the principles and policy of public health. We are oriented towards the future in terms of services. There are similarities with education in that regard. We work closely with those involved in education.

On HPV, the cost is divided between the cost of the vaccine and the cost of delivery. Teams in place in community health services vaccinate schoolchildren. There is a good uptake and a good relationship with schools. It is one of the ways forward.

Deputy Jan O’Sullivan

What would the cost be of adding HPV to what is in place?

Dr. Clare O’Sullivan

The cost of the vaccine. I am sure there would be extra costs because there would have to be adequate resources in place to provide three doses for each girl. In an ideal world, each boy would receive the vaccine also to provide population and herd immunity. The vaccine would be delivered by a team made up of nurses and doctors in the community.

Dr. Peter Nolan

As well as administrative staff who are very important.

Dr. Clare O’Sullivan

Our staffing arrangements are pressurised because we have not been able to replace staff. We are under pressure from that point of view. We are fully committed to the idea of having teams within the primary care system. We see the great advantage in having occupational therapists and physiotherapists in place to make quick referrals and carry out specialised work within the network.

Deputy Paul Connaughton

How soon is it envisaged that this will be in place? Does it depend on 1,000 factors? This is the correct model but we are a long time talking about it and a long way from it.

Dr. Clare O’Sullivan

It is being put in place in some areas. I am involved in the local implementation group in the Carlow-Kilkenny area. Professor Drumm will be present at the opening of one of the primary care team areas tomorrow. There is still a resource problem with regard to the building but I understand it is under way. It is beginning to happen but most teams are not adequately resourced or staffed. The team is not just about GPs, but about others also. It is an exciting time if we can get the resources we need but these are stringent economic times.

Senator Liam Twomey

The HSE is ring-fencing €200 million to provide buildings for primary care teams, yet it cannot provide an occupational therapist. Should there not be a change in policy?

Dr. Martin Daly

We have evidence of occupational therapists and physiotherapists who have been appointed to primary care teams and are operating from their cars. They must have the physical space in which to operate. There is no point in appointing a physiotherapist if he or she does not have a site from which to work. It must involve a combination of the two. We keep hearing the same announcements of the same primary care teams over and over again. Three years ago 93 were announced. One suspects that each time this is announced some manager in the HSE is getting a bonus because he or she has hit the numbers.

Deputy Charlie O’Connor

Do the delegates talk to each other? I do not understand how the HSE can allow systems and programmes to develop, apparently without talking to anyone on the ground. That is what is coming across.

Dr. Martin Daly

An example involves the setting up of primary care teams. There was a major problem of credibility in some areas. The HSE made contact with certain groups of GPs in a particular area and spoke to them about providing for a primary care system without advertising for expressions of interest to become involved in such teams. This does not refer to buildings but to teams. This caused great tension on the ground. There were false starts and false dawns but this is about communication. There is a need for a clear strategy. An example involves the manpower issue. They are saying one thing but are suppressing lists around the country.

Chairman

On behalf of members, I thank the delegates for their presentation. We may have to revert to them for further information as we compile reports. The points on the GMS raised by Dr. Daly, as president of the IMO, are fundamental to the broader work of the committee. After we have finished our report on primary care, we would like to talk to him about the GMS. There is public awareness of the importance of GPs. The committee is aware of the high level of patient and public satisfaction with their work. We look forward to engaging with the delegation on the subject of the GMS.

Sitting suspended at 1.05 p.m. and resumed at 2.05 p.m.