JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 10 Feb 2009

Alpha Healthcare Limited and Mallow Primary Healthcare Group.

Chairman

I welcome Dr. Jack Nagle and Dr. Finbarr Corkery from Alpha Healthcare Limited and Dr. David Moloney, Dr. Tony Heffernan and Dr. Harry Casey from Mallow Primary Healthcare Group. We look forward to their presentations.

Before we commence I draw attention to the fact that members of this committee have absolute privilege but the same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice that members should not comment on, criticise or make charges against a person outside the House or an official, by name or in such a way as to make him or her identifiable.

Dr. Nagle has been following our deliberations over several days and is familiar with the format of our meetings. I ask Dr. Nagle and Dr. Moloney to make brief presentations and these will be followed by questions from members.

Dr. Jack Nagle

I thank you, Chairman, and the committee for giving me this opportunity to outline Alpha Healthcare's submission on primary medical care in the community. I am joined by Dr. Finbarr Corkery, chairman of the company.

I am delighted to outline our role as programme managers, or professional facilitators, in the delivery of these primary care centres nationally. Primary care centres are an integral part of the national primary care strategy, bringing general practice and HSE services together for improved delivery of services to the community. Our company is currently involved in more than 20 projects across the country, ranging in size from 20,000 sq. ft. to 100,000 sq. ft., at a project cost of between €8 million and €40 million per project. In our model, the company works collaboratively with GPs and the HSE. We bring together all the necessary legal, financial and other professional services and fully programme manage these on behalf of GPs to deliver the primary care centre building. We make it happen and we have a track record of delivering.

In all our projects, Alpha Healthcare remains as a service provider and programme manager for the GP consortia and other health care professionals. The company takes no ongoing ownership stake in the building. We are certified to ISO 9000, highlighting our commitment to delivering high standards of service within the primary health care area. These buildings are not just about bricks and mortar design. They are about understanding the integration of services being proposed between GPs and the HSE and the inclusion of future medical service provision within these centres. These are to be delivered within the community, in line with the national health strategy.

The GPs, in taking a leadership role in these projects, have provided a vision and direction for future community service delivery from these centres. Crucially, the Alpha model facilitates GP involvement from the beginning, together with the HSE, as well as affording GPs the opportunity to retain ownership of their primary care centre facilities. I am delighted that GP representatives from two of the flagship centres for which we are programme managers will also make a submission to the committee, outlining their experiences and vision for their centres.

We support the Government and HSE strategy to promote primary care in the community, with the aim of establishing integrated services within purpose built primary care centres. Invariably, the need to develop the new systems and structures for the HSE to lease these buildings has led to administrative delays in some of the projects. If the HSE implements its full programme to source 250 primary care buildings more than €2.5 billion will be injected into the construction sector at a time of great need. This would happen at no cost to the Exchequer in the next two years while the buildings were being designed and constructed. The HSE is citing a need to achieve a 30% reduction on market rents before it will lease space in a primary care centre. This level of rental reduction, even for a long-term lease and a State body, is making the bankability of projects difficult and discouraging GPs from becoming involved in projects in some areas. A genuine effort is required to increase the commercial attractiveness of some projects to GPs and other health care stakeholders if the roll-out is to be truly successful.

We ask the committee to provide ongoing support for the current strategy and plan to develop primary care centres nationally; to actively seek a streamlining of the HSE procedures for the leasing of space within units in order that projects can proceed in a more timely manner; to provide support and an incentive for GPs and other health care professional stakeholders to take an ownership and leadership role in the development of primary care centres; and to help address the bankability issues associated with such projects.

Dr. David Moloney

I am a GP from the Red House family practice in Mallow. I am accompanied by two other GPs from Mallow, Dr. Tony Heffernan from the Cork Road clinic and Dr. Harry Casey from the medical centre. We are developing the Mallow primary health care project and have provided some pictures of how the project will look. It is designed to the health technical memoranda standards of the NHS, as there are no equivalent standards in Ireland for disease prevention. It is an attractive building which is designed to be user friendly with plenty of parking space, allowing easy access for patients and with an open landscape. The goal is to deliver enhanced primary health care services to the community of Mallow in keeping with the primary care strategy 2001 and to meet future highest standards of patient care in co-operation with the HSE staff and others.

The background to the project involves the coming together of three group practices employing 17 doctors and eight nurses. Mallow has a population of 22,000 which is projected to increase over ten years to 32,000. The building is 70,000 sq. ft. and being built at a cost of €21.2 million, plus €3 million VAT. It will bring patient primary care to a new standard. We want to keep the best of what is present but integrate all the other primary care services and provide an infrastructure, enhanced services and for future development. The origins of the concept lie in Shaping a Healthier Future — Primary Care Strategy 2001, under which all primary care professionals work together for patient benefit. This will achieve economies of scale and ensure less duplication of services.

There are many good points about general practice to which I refer in my presentation. There are, however, challenges to the development of primary care centres. This is a big project and its size makes it a daunting task. Financing is becoming more of a challenge. Time spent in planning and progressing the project is enormous. The HSE has a new model of development which has had an impact on us. The current status of the Mallow project is that building work is commencing. The HSE lease has been signed and finance was arranged with difficulty. Construction is expected to last 14 months. Planning for new services is ongoing. We are attempting to organise equal access to public and private services.

There are many reports on primary care which detail the type of project in which we are engaged and it is supported from all areas. To ensure its success we need equality of access for public and private patients alike to all the services that will be provided in our new primary health care service. We require ongoing HSE support and service development, as well as an integrated IT building which will help in the delivery of primary, secondary and tertiary care in hospital, in addition to support with our education initiative and some financial incentives or support.

Chairman

I thank both delegates for being so concise.

Deputy James Reilly

I welcome the representatives of Alpha Healthcare and the Mallow primary health care project. I also thank the witnesses for their concise three-minute presentations, which make life easy. Both speakers alluded to bankability and both should respond separately on the issue and their suggestions to address it. Given that the Mallow centre is out of the ground, can Dr. Moloney circulate pictures to members to provide them with a sense of what will be built there? Are there plans for X-ray, ultrasound, MRI and endoscopy services, as well as day surgery or rooms for visiting consultants? I have the pictures to hand and the building looks highly impressive.

Deputy Jan O’Sullivan

I welcome the delegations and will follow everyone's example by being brief. The witnesses should outline the general benefit to patients of having such centres. Dr. Moloney referred to access for all patients and should clarify whether all patients, both private and public, have access to the entire team, including therapists and so on, as well as to the doctors and nurses. Dr. Moloney referred to the issue of information technology, IT, and suggested an IT building. There seems to be scope for more interaction between GPs and hospitals in a locality through the greater use of IT. For example, GPs may be able to send information to hospitals regarding patients who are being admitted, while the opposite may apply when patients are discharged into the community. The witnesses should outline how they see this developing. I note the GP group in Mallow also has been closely linked with the hospital there and this may be a model with which one can save both money and time in respect of patients getting access to hospital when required, as well as being discharged when ready.

I also am interested in the issue raised by Deputy Reilly regarding bankability. Dr. Nagle referred specifically to the HSE seeking a 30% reduction in market rental. What is the reason for this, given that the HSE presumably rents properties nationwide for its use at market values? Why does it seek 30% less in respect of primary care units? As the delegations seek members' help in this regard, they should make suggestions on what the joint committee might recommend.

Deputy Rory O’Hanlon

Is it correct to state that Alpha Healthcare Limited is involved in the buildings, together with the GPs? I refer to the centres in the towns around the country, as outlined by Dr. Nagle.

Dr. Jack Nagle

We are programme facilitators or project managers. We neither own any of the buildings nor take a stake in them.

Deputy Rory O’Hanlon

Dr. Nagle stated that GPs have ownership of their part of the building.

Dr. Jack Nagle

That is correct.

Deputy Rory O’Hanlon

What of other stakeholders, such as pharmacists, were they to operate from the building?

Dr. Jack Nagle

There are different models.

Deputy Rory O’Hanlon

Perhaps I should ask the questions first before Dr. Nagle responds. I refer to Alpha Healthcare's role when a primary care centre is up and running. Does it have a role in the co-ordination, co-operation and integration between the different people who work there? While I do not refer to Alpha Healthcare's centres in particular, I am concerned that a number of agencies that work in primary care centres report in different directions and consequently, there is not necessarily co-ordination at local level. In other words, a GP does not necessarily always know what is happening to his or her patient as some health care workers report back to the public health services or to an agency elsewhere. Do the witnesses have views in this regard?

My other question pertains to Killarney, as GPs from that town will appear before the joint committee this afternoon. Are they linked in any way to what the delegates are doing?

Senator Geraldine Feeney

I thank the delegates for their excellent presentations. Witnesses score immediately when they keep their presentations short and crisp. What they have described is a wonderful initiative. There is a similar project in Sligo, where I live, which runs very well. The majority of GPs in the town are under one roof. It is superb to have a facility, as in Mallow, offering the services of 17 doctors and eight nurses.

Was the facility at Mallow built on a private site or is the site connected to the Health Service Executive? What is its proximity to the local hospital? The delegates said they seek support for their educational initiatives. Is this a reference to continuing medical education, CME, or are the delegates talking about a trainer-trainee scheme?

Deputy O'Sullivan asked about the delegates' objective of ensuring equal access for public and private patients. What is the percentage breakdown of public and private patients across the three practices?

Deputy Kathleen Lynch

I welcome the delegates. The Mallow project involves 17 doctors. The town has many new residents but also a substantial elderly population. Older people in particular may have an affinity with one GP as opposed to another. Is it possible for patients to choose to be treated by a particular GP?

Some GPs, while operating in the general medical field of primary care, also have particular specialties. Will this be accommodated within the practice structure? Will an out-of-hours provision be part and parcel of the service or will patients still be obliged to go to SouthDoc?

Senator Geraldine Feeney

I have one other question. What other health care providers will be accommodated under the scheme?

Chairman

The delegates referred to the process leading up to the signing of a lease. I got the impression from what they said that this may be a lengthy process. Will the delegates expand on that? There was also reference to significant difficulties in financing projects. Do the delegates have any proposals to put to the committee in this regard?

What is the potential for these types of centres to develop organically? Is there need in most instances for the type of facilitation role that Alpha Healthcare Limited and other such companies provide?

Deputy Kathleen Lynch

Will the delegates also expand on their comments regarding access for all patients?

Chairman

In the course of our deliberations on this issue, the question of patient access has emerged as a key factor. It was first highlighted to the committee by nursing representatives, for whom it is an issue of particular concern.

Dr. Jack Nagle

I shall address what may be referred to as the project management and financing aspects. My colleagues will respond to the questions on medical issues. There were several questions regarding bankability, financing and leasing arrangements. Mallow is one of the first projects to be involved in the process with the Health Service Executive. That has advantages and disadvantages. The main advantage is that the group is at the cutting edge in terms of service delivery. The main disadvantage is that everything has to be developed. There has been a significant degree of collaboration between the Health Service Executive and GPs at all levels. That said, there is much to be done before one gets to the point where the Health Service Executive has the appropriate legal structures in place to lease the buildings. That has been a complicated and arduous process. The expectation is that will be significantly simplified as we move forward.

In regard to the bankability and the question of the reduction, this is an initiative from the HSE where it is seeking to get value for money. Rather than building the structures from a capital point of view, it has looked at the attractiveness of leasing on a long-term basis. I have seen some of the cost benefit analysis, and as I understand it, it is its way of seeking value for money which I fully support and endorse. However, pushing for a 30% reduction in some instances makes these unbankable.

A further comment on the bankability of these projects is that if the HSE is seeking a 30% reduction, clearly this must be made up elsewhere. When we present the lease proposals and these structures to the banks, that poses difficulty as regards their financing. One of the recommendations we would make would be that the committee might seek ways in which this reduction in market rental could be reduced or a greater rental paid to groups interested in developing these centres.

On the question of other stakeholders being involved I see the potential for that happening. I believe the group appearing after us, GPs and dentists, have formed a consortium. There is nothing to stop a broader consortium of health care professionals getting involved. I suggest the reason there are so many GP-led initiatives is that GPs have a central role to play in the primary care strategy. The HSE has given them a central role. They have traditionally taken a leadership role in the clinical side and are now taking a leadership role in the development side. I hope I have answered those questions appropriately. I will pass the other questions to my colleagues.

Dr. David Moloney

Deputy Reilly mentioned the building itself and the structure. The building is very friendly. It was built specifically for the purpose. It is not an adapted building and it will be built to deliver. Both the GPs and the HSE involvement came through a design process — that was part of the reason it took so long. While organising our lease arrangements the HSE would have designed its own premises within this building, as we did, to make them as friendly as possible. On the issue of the building being friendly, Deputy Lynch mentioned the concept that people like to see their own GP.

As I mentioned in the presentation we are keen to retain that which is good in general practice and which has worked and which is delivering at present. One of the things that delivers is the fact that we know our patients and they know us. We know their needs and we are able to deliver much more quickly on that level. Three practices will occupy the building, not 17 doctors forming a new practice. The practices are going in as they are now with their own staff into their own premises which will reflect the ethos. There is a difference between each practice one way or another and that will be maintained. The personal contact is essential in delivering primary care. Probably one of the strengths of primary care is that people see their own doctors.

Within the building we will have the facilities for inter-referral. Inter-referral has been a concept of medicine encouraged by the College of General Practitioners for a number of years. It becomes more feasible here where individuals within a group of 17 doctors will have extra interests and extra sub-specialties and will be able to deliver a better service to their patients. From that point of view the building is designed to deliver this product and higher standards of care into the future.

Dr. Harry Casey

Because of the increased number of patients — some 20,000 between three practices — we can deliver a number of care services, specifically chronic illness care, at a more specialist level. Initiatives in which all three practices have been involved include the diabetic initiative. They are also involved in rheumatology, heart disease and travel medicine initiatives. We expect doctors to specialise in these areas and patients to benefit from the improved quality of care at primary care level.

A question was asked about other professionals who might be involved. It could be a long list. We are just starting building work but envisage a number of physical therapy specialists, including physiotherapists, chiropractors and osteopaths, being involved. We also envisage opticians and audiologists being involved and that there will be a crèche for mothers visiting the practice. We can provide these services because of the number of patients visiting. They cannot be provided currently at individual practices.

Someone asked whether we would provide for the taking of X-rays, ultrasound and MRI scans. We would be loath to develop such services until there is equality of access. In our centre we want to ensure equality of access for all patients, both medical card and private patients. Approximately 30% of patients in the three practices are medical card holders. All practices have always sought to ensure equality of access to all services and we want to bring this ethos to the new centre. The development of services depends on how we can ensure equality of access for patients through negotiation with the HSE.

Dr. David Moloney

Deputy O'Sullivan asked about the benefits to patients at a centre such as this. We expect patients to receive a higher quality of service which is near to them, efficient and integrated. By having people in the same building there will be greater teamwork between GPs, HSE and ancillary staff. Their proximity alone will make a difference. We also expect better communication and information. Communication presents one of the biggest problems. That we are able to communicate with people is probably one of the saviours of general practice.

We expect the centre to have disease prevention and management functions, both acute and chronic disease. Chronic disease management is one of the major elements of general practice — it is what we do. We see the same people who have different illnesses, while hospitals are more inclined to deal with patients who have illnesses. In centres such as this we can take care of more of these problems. A good example is diabetics who consume some 10% to 15% of the total health budget. There is no structured care programme for them. They are overcrowding hospital services which cannot deal with them. Endocrinologists cannot deal with them. The expert advisory group set up to address the issue has stated it must be managed within primary care services. To provide such services, one needs facilities and staff. We will send patients with difficulties beyond our control and capabilities to hospital where consultant delivered services are available to them. This makes it more efficient for them.

Other groups, including rheumatoid arthritis patients, will receive a better service. We will upskill nurses and doctors who will take a special interest in these areas in order that there will be a critical mass that will be able to deliver services to patients within the primary care setting. There is also plenty of room for mental health services which are badly needed in the community. This is exactly where they should be provided — in a primary care setting.

The ethos in general practice of same day delivery is a further benefit. We are not into waiting lists but making things happen and seeing services delivered. That is why we are here. We want to enhance services and bring them to patients. We can see a new primary care service delivering for our patients on a day-to-day basis.

Other services will be available. We have osteopaths, chiropractors, counsellors, dieticians and other ancillary services. As a result, we can efficiently deliver a service within a realistic setting because we know our patients, an important factor.

IT will be critical. This will be an integrated building in which people will use uniform information with degrees of access. We expect patient registration, an Irish college prerequisite, with which we agree. With a proper IT service, there would be a safer patient environment with greater efficiency and integration. This will lend itself to a major area of general practice not currently utilised — research. We will be able to research community-based medical practice and continuing care services. A building with proper IT facilities can be audited. All processes can be examined and we will be able to ensure everything bears scrutiny. It will be a fair and reasonable way to look at things. IT is essential in such a building, both to the HSE and general practice. Most general practices use computers but we must move on. Medicine is dynamic, it is changing all the time and we must keep up. The medicine I practised when I started 26 years ago was very different. Then, two doctors used one surgery, whereas today six doctors and three nurses in my practice use ten clinical rooms. This must continue to deliver a service to patients.

Dr. Jack Nagle

I would like to add to some of the points made by Dr. Maloney. There is direct and easy access to GP services as well as to HSE services, something of great significance to Mallow where currently the HSE is located in 14 premises. It is not necessary to explain the burden this places on a patient. There will be integration of all these services under one roof. The building has been designed in such a way that when Mrs. Murphy arrives at the centre, in front of her she will see three practices. Once she enters, she will be among familiar faces and see her own GP and practice staff as before. Such simplicity took a long time to achieve. In designing the building we visited centres in the Republic, the North and Britain. In Britain we looked at a centre in Bromley-by-Bow where a holistic view is taken to community services. We have imported that process into the design of the building.

Senator Feeney asked if this was a private or HSE site. It is a private site and the building is being constructed by a local developer who has been hugely supportive of the project and travelled to Britain with us to see the various sites in order that he could play his part in providing a health care building. I would clarify to Deputy O'Hanlon that our role is purely as facilitators. We will programme and project-manage this, and when we finish we will hand the building to the GPs. We take no ownership stake in the building. These are very exciting developments and there is much interest from GP groups and other health care professionals in getting involved in them. Getting these groups together is very powerful.

I should convey the many days and hours that the GP groups have spent in getting to this point. We set up an executive management group structure, of which Dr. Moloney, Dr. Casey and Dr. Heffernan are the lead group at the moment. Within 24 hours, they would be at my beck and call to sit down and review whatever came up in the project. We would have our meeting, a decision would be made and we would drive on. It is a very efficient and effective way to get the projects off the ground by involving the key clinical leaders.

We also adapted these meetings and involved the HSE in exactly the same process by bringing the GPs and the HSE together, which enabled the project to move forward in a very timely manner.

Deputy Kathleen Lynch

What about an out-of-hours service? Maybe it is because I am not taking in the information properly but I still do not know anything more about equal access to patients.

Dr. Jack Nagle

Perhaps my colleagues, Dr. Heffernan or Dr. Corkery, could deal with those issues.

Dr. Tony Heffernan

We already have an out-of-hours service in our area. We aim for it to be based in the building. Everybody has equal access at the moment but we would like equality of access for additional services. This goes to the core of what we do and relates to the advocacy role we have always had for our patients. We do not want to provide a building with magnificent services, only with 70% of the patients private and 30% on the medical card. There are some services only available for medical card holders that should be available for public patients as well. We would like equality of access and we are in the process of discussing with the HSE how this may be done. We would not like to promise services that will only be available for a select few. We want to look after all our patients equally.

Deputy Kathleen Lynch

I thank the witness.

Dr. Tony Heffernan

Deputy O'Hanlon had a question on the governance of information transfer, which is important, and Senator Feeney asked about the education centre. I got the easy part of the question as this is the exciting part of our development. Our education centre is developed on the basis of all practices involving postgraduate and undergraduate training up to now. We have forged great links with nursing and medical undergraduates, and with UCC in particular. Other colleges and universities, including the Irish College of General Practitioners, want to have increased involvement of their students in primary care to learn medicine where the people are. We wholeheartedly support that.

We want to take this a step further. The committee has already asked who would be on the primary care team. Without considering any document, the most important part of every team would be the patient. We will have an education centre, which will take up a large proportion of the building at reasonable financial risk. It is planned to have this at 2,000 sq. ft. to 5,000 sq. ft. We are calling this "transforming primary care through multidisciplinary training."

I will make this easy as it involves four words — TEAM, imagine it now. "T" stands for team training, which involves patients, administration staff and professionals. "E" is for education and research. At the moment we have an indicated research project between the three practices on diabetes. One of our practitioners, involved with the university in South Africa, is developing an e-protocol for consultation and communication skills. As of tomorrow we will try to expand, between the three practices, a research project on falls in the elderly. "A" is the important factor mentioned by Deputy O'Hanlon, audit. It is no good doing all these magnificent feats if we cannot produce research at the end of the day saying what is beneficial. It must be an open and objective audit. "M" stands for the management of change. Obviously, this will be a considerable change for all of us, as we have had the process for the past four years or so. However, the change will be significant for everyone involved, including patients and staff.

"I" is for innovative and integrative, involving every stakeholder, namely, patients, HSE staff and us. The HSE has been involved in all aspects of the building's development and is actively involved in the education project. Tomorrow, I will make a presentation to it on how far we have progressed our project in recent months.

"M" is for multidisciplinary. We will approach it on a modular basis.

"A" is for all-inclusive. We have already established a patient participation group, PPG. At a workshop in December, most of the information came from patients. In one meeting with them, we got more information about where we were going than we had gathered in the preceding 12 months. This was heartening, but almost embarrassing at this stage of my career.

"G" is for groups and individuals. Rather than it only being a matter of individual training, groups and communities will be involved. We would also appreciate help from the Diabetic Association and the others involved. "I" is for interactive and informative. There will be a flow of education through the building, its different occupants and the PPG. "N" is for national and international. We have made links with colleges and people abroad to help us in our project. "E" is for ever expanding, as it cannot stay still.

"IT" is for information technology. Before reverting to Deputy O'Hanlon, HIQA described IT as being a "public-friendly, robust information governance framework". We would like to build our system using this definition. Thankfully, our project is under way.

Deputy David Stanton

I apologise for being late. The project sounds innovative and exciting, but I have a question on osteopathic and physiotherapy services for medical card patients. Our guests know that the waiting lists are long and it is difficult to access the services, but the situation is not adequate. Rather, it is quite limited. Do our guests have proposals or arrangements on equality of access so that medical card patients in particular can avail of private physiotherapy or osteopathic services from the centre? Is this how it will work?

Deputy James Reilly

As I was not present and after asking one or two colleagues, I am unsure as to whether my questions have been answered. Both parties mentioned bankability and the problems surrounding the 30% figure. I am told that the HSE will decrease the figure to 18%, but I do not know whether this information is official. The HSE is of the opinion that tax incentives would not, at this stage, be of benefit to the further promotion of the project. In this regard, I would appreciate the opinions of those sitting across from me.

Regarding X-ray, MRI, ultrasound and endoscopy, are rooms available for endoscopy and day surgery? Was this question answered in my absence?

Concerning Deputy Stanton's two questions, osteopaths and chiropractors are not covered in the GMS and I doubt that they are available to our guests' patients. There will be an inequity. If the facilities have been built and are being used by private patients covered by insurers, surely there will be a significant demand for them from the medical card population. A number of years ago, a HSE initiative in my area saw practices being issued with several tokens to allow them to refer patients to private facilities for ultrasounds and X-rays. Our guests could consider this initiative. Has room to accommodate these diagnostic facilities been left in the building? Alternatively, due to Mallow's nature, will the local hospital provide those facilities?

Chairman

My gentle nature has been taken advantage of. I will allow a brief comment from Senator Feeney.

Senator Geraldine Feeney

I thank the Chairman for allowing me to speak again. Dr. Moloney referred to the considerable scope in terms of mental health. Will he elaborate in this regard? Did he mean a psychiatric nurse? Is his group engaged in a scheme whereby it trains GPs? The scheme, as outlined, sounds like it would be a wonderful experience for a trainee GP.

Deputy Margaret Conlon

Does Alpha Healthcare have a further role when a facility is commissioned?

Deputy Rory O’Hanlon

Does the Mallow group have a link with the Killarney project?

Dr. Tony Heffernan

We are already three training practices and we have trainees at various stages. This will be a vital part of their training. We have already contacted the colleges on this matter.

With regard to Killarney, apart from friendly rivalry on the football pitch and seeing each other at meetings, as GPs we have no direct connection with the Killarney project.

Dr. David Moloney

Senator Feeney mentioned Sligo. This was one of the first places we visited when we started four or five years ago. She also mentioned mental health. That needs to be brought into the community. It is an integral part of our problems in life and needs to be dealt with openly within a community setting, such as a primary care centre.

Deputy Stanton asked about osteopaths. We envisage such services being provided by people who will set up privately as associate ancillary practitioners. The logical option for the HSE would be to allow a certain number of visits to such practitioners and pay for them, rather than employ another layer of people with full contracts in the HSE. It makes more sense to support existing services that are being operated privately.

Deputy David Stanton

They are not doing that at present.

Dr. David Moloney

No.

Deputy James Reilly

Was room left in the building for X-ray, ultrasound and endoscopy services?

Dr. Tony Heffernan

We have left room for expansion on all fronts, including extra patient care.

Deputy James Reilly

What about tax breaks?

Dr. Jack Nagle

I have made a recommendation regarding the bankability of the projects and the reduction sought by the HSE. The committee may look at my recommendation with a view to seeking an easement of that. I would support any incentives the committee might suggest to support GPs and other health care stakeholders to become involved in the development of these buildings. It is a current issue.

Dr. David Moloney

We have designed this building for the future. When we visited many of the other centres we saw that many were designed for current but not future needs. We have put planning permission in place for extensions to the building if they are required in the future. We hope this project will deliver for many years to come.

Dr. Jack Nagle

May I answer Deputy Conlon's question? Our role is as facilitators and programme managers. We take no stake in the building. When it is finished it is handed over to the GPs. We may have an ongoing facilitatory role because we do practice management with some groups and we are currently working with some practices. However, we have no ownership stake whatsoever in the buildings.

Dr. Finbarr Corkery

May I stress that point? There are two parallel fields of expertise. Doctors provide clinical services. However, the provision of physical and administrative infrastructure is a task for which doctors are not trained and in which they are not skilled.

Chairman

I thank the delegates for their very helpful presentations and I congratulate them on the impressive work they are doing.