GP Out-of-Hours Service: Discussion with HSE

Today we have a presentation from the Health Service Executive on the doctor on call service. I welcome Mr. Tadhg O'Brien, assistant national director, integrated services directorate, and Mr. Patrick Burke, who is no stranger to the committee, assistant national director of primary care reimbursement services.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable.

I invite the representatives to give the committee a synopsis of the position on the GP out-of-hours services following which I will take questions from members.

Mr. Tadhg O’Brien

I thank the Chairman and members of the committee for the invitation to appear before the committee and make an opening statement.

The HSE national review of GP out-of-hours services was the first national review to be undertaken since publicly funded GP co-operatives were introduced in 1999. In the context of the need for the HSE to meet targets for efficiency savings, to protect services and deliver maximum operational efficiency, this review provided an opportunity to consider the nine national GP co-operatives and the four extended hours services in Dublin south city.

The report's 13 recommendations which are aimed at standardising the operation of the co-operatives are challenging and will require a significant level of commitment to implement. The cost to the State of providing this service is €107 million per annum and is made up as follows: payment to GPs, €62.2 million; call centres, €15.5 million; and treatment centres, €29.3 million.

One of the key issues addressed by the review relates to the method of payment for GP co-operatives. Seven of the nine co-operatives are currently paid on a fee-per-item basis and the other two, namely, DDoc and North East Doc, NeDoc, are paid a grant.

The main issues arising from the review are the following: a standard approach to payment should be introduced across all the co-operatives. The payment should be on a fee-per-item basis; the number of call centres should be reduced from seven to four - one for each region; the most cost-effective method of triaging is quality assured nurse telephone triage; a standardised service level agreement should be applied to all co-operatives; each region should examine the current provision of treatment centres, which currently stands at 75; each region should examine the role of drivers for the co-operatives; and each region should engage with non-participating GPs to ensure 100% out-of-hours coverage nationally. These recommendations are being implemented by the HSE integrated services directorate.

Since publication of the report, the HSE has met with the Irish Medical Organisation and agreed a joint approach to implementing the review and has established a joint working group with the IMO. Our terms of reference are as follows: the working group will be made up of representatives from the HSE and the IMO, the IMO representation will include representatives from the Irish Association of General Practitioner Co-operatives; the group will hold discussions and seek to reach consensus on proposals for arrangements and models that are cost effective and mindful of patient care, within the terms and conditions of the current GMS contract; in line with the Croke Park agreement, the working group will not in any way seek to change the terms of reference of the existing GMS contract; the group will conclude its work no later than 1 March 2011. This will not affect the parties making agreed changes on a phased basis prior to completion of the agreement; the HSE national review of GP out-of-hours services, together with the response of the Irish Association General Practitioner Co-operatives and responses of individual co-operatives, will form the basis of the group's discussion; and the HSE will be represented by me, Mr. Patrick Burke, and Ms Anna Marie Lanigan. The IMO will be represented by its chief executive, Mr. George McNeice, Dr. Ronan Boland and two general practitioners from the Irish Association of General Practitioner Co-operatives.

I thank Mr. O'Brien. Does Mr. Burke wish to make any comment?

I welcome Mr. Patrick Burke and Mr. Tadhg O'Brien. The GP co-operative out-of-hours service has been one of the more successful initiatives to emanate under the HSE. I would be concerned that the availability of GP out-of-hours services be maintained to reduce the reliance on people presenting at hospital accident and emergency departments. Any comments the delegates may have to offer on this matter would be useful. I am concerned at newspaper reports that some co-operatives have not had Garda vetting carried out on locums acting on behalf of doctors. Clearly that is not acceptable and has to be done. Is there any explanation as to why the nurse triaging provided by CareDoc is so expensive in DDoc as opposed to the rest of the country?

The satisfaction rating in respect of the service appears to be quite high but given the variation around the country, perhaps the delegates would address that issue. What is it hoped to achieve from the review? Is it purely to save money or to ensure greater cover? How will accessibility be affected if the number of call centres is reduced from seven to four?

I thank the HSE representatives for appearing before the committee. My first question centres around the fact that GP out-of-hours services are not long in situ and were set in different parts of the country under different models. I presume the intention is to have the same type of model everywhere. Is it the case that certain elements of some of the services work very well? Is there a best practice model that is really efficient that gives patient satisfaction and also takes the pressure off the emergency departments in our hospitals. One of the main functions of the out-of-hours services is to give the patient a service but also to assist GPs particularly in large areas. They also fulfil an important role in relieving pressure on accident and emergency departments. I see a headline in the Irish Medical Times, “DDoc in crisis” and a number of co-operatives have expressed concerns about elements of what is being recommended. Deputy Reilly, who is a doctor, expressed concern about an element of the service. I too have concerns about the idea of having just four call centres. My own area is HSE west. Will the whole of HSE west be covered by one call centre and if so, what reasons will determine where that call centre will be located? The role of drivers for the co-operatives was raised in the presentation. I spoke to a person at a senior administrative level in one of the co-operatives about employing drivers. Is the alternative to having drivers that doctors themselves would drive around at night-time? Will the delegates clarify the alternative proposals in respect of drivers for the co-operatives?

I thank Mr. O'Brien for his presentation. Seven of the nine co-operatives are currently paid on a fee-per-item basis and in the other two co-operatives, staff are paid a salary. The IMO and the Irish Association of General Practitioner Co-operatives will nominate members to a committee to look at this. I acknowledge this is not a matter for Mr. O'Brien but I would like him to bring my suggestion to the attention of his contacts, that perhaps one of the two general practitioners from the Irish Association of General Practitioner Co-operatives might represent those two co-operatives that are paid a grant from which salaries are paid to staff, rather than have all the general practitioners representing the co-operatives that operate on a fee-per-item basis. This will lead to a much better debate and one will see why they might be happy. I do not disagree with negotiations on the organisation of co-operatives. In comparing the organisation of an out-of-hours service, I have no doubt that it is a very important to retain this necessary service. The idea of GPs working longer hours is long past so one needs to provide a proper out-of-hours service for the benefit of the people as well as keeping the pressure off the hospitals. It is important that this service would not be diminished.

There must be different ratios of staffing in the different co-operatives. Have some general practitioner co-operatives more staff or provide services in different disciplines? I am not against looking at how to achieve the maximum efficiency in the context of the Croke Park agreement.

There is a question of reducing the existing seven centres to four call centres. However, I would be more concerned about retaining the 75 treatment centres. That is very important and certainly in Dublin north east it is very important to keep the four treatment centres. Journeys are particularly long and the way quickest to get more people to go to hospital rather than to the GP in the middle of the night is to move the treatment centre further away from them. The Cavan Monaghan centres work quite well but the distance people have to travel is at the extreme end and to close either centre would send people straight to accident and emergency departments. It would be grossly unfair to compel people to travel longer distances than they do at present.

I thank the delegates for the presentation. I have had representations from the drivers of CareDoc who state that their response vehicles are not designated emergency vehicles and as a consequence the new speed cameras will have an impact on the response time they will give to patients. Is there a proposal that these vehicles, which are quite easily identifiable, could be designated as an emergency vehicle or has Mr. O'Brien a view in that regard?

I welcome both members of the delegation. Several weeks ago I brought my son to an eye clinic in Waterford regional hospital. The eye clinic is a routine service and I watched as the secretaries pulled a trolley load of paper files behind them. If I wished to e-mail Waterford regional hospital or my own regional hospital, I cannot. CareDoc is the out-of-hours service in County Wexford yet every single consultation that I do, be it in the CareDoc clinic or in the patient's house is computerised and I e-mail my notes to the relevant GP from the patient's bed or from the desk from where I work. It has been a fantastic service. It works because it is well organised and has a major commitment from the HSE and the doctors involved. I think along the same lines as Dr. O'Hanlon and whatever about reducing the number of call centres, the 75 treatment centres around the country are probably sufficient. There are four treatment centres in the whole of County Wexford, which from end to end is more than 70 miles long and I think we would diminish the service if we reduced the number of centres too quickly. Keeping the public good-will is what has sustained the service in recent years. The service is relatively accessible and people are seen in a timely manner.

When the delegates suggest reducing the service, what savings will result? If one manages to get all the general practitioners to accept a fee-per-item what savings will be made on payments to GPs? If the number of call centres is reduced what saving will be made and what are the potential adverse effects? I do not think one can reduce the number of treatment centres, but what changes are involved in reorganising the type of services that are provided in the treatment centres? What are the expected savings? The committee would have a good idea of the thinking if we had some idea of the level of savings expected from it. There is a need to be careful in reducing the service because in comparison to any other emergency service provided by the HSE, the general practitioner out-of- hours service is by far the most cost effective. It gives excellent value and it is an excellent service from a patient safety perspective.

It is a first class service. I do not know enough about it to criticise it but from personal experience, I know the service is first class.

Why are some GPs not participating in this scheme? What are the reasons that the GPs are not taking part in this scheme?

I take up the sentiments expressed by members on the high level of public satisfaction with the 13 co-operatives across the country. When they started people who were used to dealing with the family doctor and nobody else were somewhat apprehensive, but satisfaction levels with the out-of-hours service are now comparable with the satisfaction levels with the family GP service. That is a credit to all who have been involved in this service. The system is working well and the delegates are reviewing it. Many would say "if it's not broken don't fix it", but one also accepts that there are significant cost disparities between the level of service provision in various areas across the country. What comes into play is this special type consultations. Perhaps he might tell us the formal contractual position on special type consultations, STCs, who is entitled to claim them and for what. Is he concerned about the level of costings of STCs in certain areas and within certain co-operatives? What sort of audit systems are in place to ensure transparency? Will he give the committee the number of STCs claimed by each of the 13 out of hours services in recent years? It would be interesting and useful for us to see this.

Deputy Aylward asked how doctors who are not involved in co-operatives claim their STCs. How many doctors or co-operatives claim their STCs electronically? Regarding triage, it appears that if the local co-operative has control of the triaging system it can set the standard for it and be responsible and accountable for what happens. However, if triaging is remote from the people providing the service there may be a difficulty. The delegates might address that point in their response. I call on whichever delegate wishes to speak first.

Mr. Tadhg O’Brien

I shall start by responding to Deputy Reilly. We did not benchmark attendances at accident and emergency departments when we developed co-operatives although that might be something we should do. Obviously, a patient will go to the most appropriate care. I agree with the Deputy that there should be Garda vetting for locums. In the review we introduced a standard service level agreement with the various co-operatives which, as members know, are private companies run, in the main, by general practitioners. Part of that service level agreement includes our insistence on Garda vetting for locums.

In regard to Caredoc-DDoc, I presume the Deputy was referring to a contract which was set up when DDoc started. There was anticipation of a huge demand and, as members know, we set up the scheme rather quickly and got a contract of €1 million for the year. Obviously, that has proved to be rather expensive, at about €24 per call so we have tendered to the EU procurement body for triaging, which should be agreed before the start of the new year.

Although it varies, the satisfaction level is 95% plus. We asked departments of public health in our local offices to look at the level in detail and it is probably the highest satisfaction rate of any services we provide. The idea behind the review was to standardise. As Senator White noted, the scheme started off at varying degrees or levels throughout the country, beginning in Carlow town. It then spread to the north east, where I had been involved years ago, and operated as a region. It moved west and then back to the south. The last service to open was DDoc in Dublin. The idea was to have a standardised approach.

We looked at the number of call centres and in that regard there was one thing we did not want to do, not for a minute. In a call centre the patient telephones, details are taken by a telephonist and the patient is telephoned back by a nurse who triages the call. It would not matter whether we had one, seven or four call centres. The idea in having four is to have one per region so that we could use the call centres to develop other services during the day.

I move to Deputy O'Sullivan's question. It is hard to say which co-operative works best because all have their strengths and there are very few weaknesses. When we were preparing this review, which I chaired, we went around the country and met all the co-operatives. There are lessons to be learned from each one. There is an Irish association of co-operatives and they meet and learn from one another. We came across nothing that would concern us. Quality is very high.

Points were made about DDoc being in crisis and that we would not meet it. Members of management for Dublin north-east met DDoc the other day and discussions are ongoing to have a service level agreement for January.

We were asked about the call centres in the west. There is a problem of management because of the size of the region. Currently there are three call centres, in Galway, Limerick and Donegal. We have left the regional directors to deal with this and we may end up having three virtual centres with one management structure. We do not necessarily say we will close two but it will be a matter for the regional director.

There was a question about drivers. Of all the questions we put to the various GPs, the one thing that emerged was that there is no alternative. They want to have drivers and we agree with them. We asked the regional directors to look at the length of time drivers are on call. For example, the other night in north Dublin we had two drivers working for the entire night.but no home visits were made. That was not value for money at its best. As Deputy Twomey knows, general practitioners go out at certain times during the day to do house calls. We suggest having a lesser time involvement for the drivers but they should be made available because even from a health and safety point of view there is a requirement at night to have somebody along, whether the doctor is male or female.

Deputy O'Hanlon asked about the fee per item with which I am sure he is very familiar. In the north east and in Dublin we pay a grant regardless of the number of calls doctors make. We find that not to be great value for money. The fee per item is currently €60 per visit for a GMS patient.

We already met representatives of the Irish association of co-operatives. Dr. Daragh O'Neill, the association chairman and a member of North East Doc, met us. Mr. Burke and I met the representatives in the Irish Medical Organisation the other day and went through the 13 recommendations. They were quite happy with our initial discussions. Regarding staffing levels we have asked the regional director offices, RDOs, to look at that matter.

There was a question about the 75 treatment centres. We did not, for one minute, recommend that they be closed but recommended a visit to see if the centres have patients in sufficient numbers. During this review there was not much time to look at 75 different places throughout the country so we have asked the regional directors to ensure that patients do not have too far to travel. The number might go down to 70 but geography is key, especially in places such as Cavan and Monaghan. We do not want to have people with children travelling too far in the dark. There may be too many centres in some towns but not enough in rural Ireland. That was the idea behind the review of the treatment centres. It was not with a view to cutting them down.

Senator Prendergast asked about drivers. When I started off the co-operatives we wanted to have a blue light service but the Garda advised us that only their vehicles and ambulances are entitled to have a blue light. We put a green light on top of the cars to distinguish them but they are not allowed to break any speed limits. In Dublin they are allowed to travel in bus lanes but cannot break the speed limit in them. This is not an emergency service but what is termed an urgent GP primary care service. There is a distinction. If a call comes into a GP co-operative which is deemed an emergency the co-operative immediately has access to our ambulance service and work hand in glove with it.

I agree with Senator Twomey that we would not have been able to start this service without the developments in IT. It would not have worked, as the Senator will remember from his old two in one rotas. There has been a huge development and we will develop it further. We spoke with the IMO last week and Dr. Boland gave us a few good examples of how we could improve service. For example, rather than sending faxes and reports to GPs we would do this electronically.

The reduction from grants to fees will save roughly €7 million and the reduction in call centres we will save about €2 million so in the current year, with the tightening up of drivers' hours we hope to save about €10 million.

In regard to the point Deputy Aylward made, we have been trying to get 100% cover since 1999 but we have identified only four large towns - Limerick, Sligo, Dundalk and somewhere in the midlands. They have not come forward yet but discussions continue. I presume local medical politics plays its part. There is a reason it has not happened but it is definitely on our agenda to have 100% cover in due time. As the Chairman said in his closing remarks, such coverage is one of our successes even though it existed before the HSE started. It was there in the time of the former health boards.

I turn to the Chairman's comments on STCs and might ask Mr. Burke to cover some of the other aspects. An STC is a special type consultation for which a GP gets paid when he sees a medical card patient out of hours. Approximately 300,000 medical card patients are seen out-of-hours and there is a charge of approximately €60 for those consultations, whereas the grant was paid whether or not doctors saw patients and proved to be quite expensive. I presume Mr. Burke will comment on his audit, which he has with him. All of these payments are paid through the primary care reimbursement centre. I do not have the detail of every claim, but may be able to provide that to the committee. As mentioned, doctors not in the co-op hope to get their claims in as soon as possible. It is our intent to ensure triage is as near as possible or connected to GPs, so that it is a GP-managed or GP- led nurse triage rather than a doctor triage, which is much more expensive.

Mr. Patrick Burke

That was a comprehensive report. I agree the system is not broken. We are making a significant investment in the out-of-hours service, but want to ensure it is as economic a service as possible. Senator Twomey mentioned that significant information is already stored in the systems in the co-ops. We want to move away from a paper based system, so there are efficiencies in that regard. I can provide the committee with details of all of the claims for special type consultations. As Mr. O'Brien said, approximately €107 million per year is spent on the out-of-hours service and approximately €42 million of that is spent on out-of-hours claims. I will provide a breakdown with those details.

The wider special type consultation, STC, provides an opportunity for patients with medical cards who are away from home for a reason to see a GP in that location. These consultations provide the opportunity for the GP to treat someone who is not on his panel in an emergency. There is also a list of approximately 15 different special services a GP can provide, such as excisions, suturing and various other services, for which he can claim. One of the areas where we are seeking to ensure a more uniform service, given that we are triaging calls that come in to the out-of-hours setting, is in generating the claim for the STC there and then and we are trying to take that uniform approach across the country. I do not have the specific numbers here, but I can make them available.

As my colleague, Mr. O'Brien, mentioned, we met the Irish Medical Organisation, IMO, last week and the co-ops are represented in that forum. We worked through each of the recommendations and there is 95% agreement on them. While further consultation will be needed to implement them, we had a useful meeting and are scheduled to meet again on Wednesday week.

I understand that GPs who are full-time contractors with the GMS are now being employed in some out-of-hours services as PAYE employees and that this has caused a problem for them because of the two different tax regimes. I understand why this happens because a number of the doctors in question do not work for the State, are not in full-time employment, move around or only work part time. However, there is no good reason that GPs who work full time for the service should be considered PAYE employees of the local HSE. Could Mr. O'Brien and Mr. Burke talk to the GPs and use their influence with the Revenue Commissioners to get this rectified. It seems to be an administrative issue and probably adds more work for the Revenue Commissioners the way it is.

The out-of-hours services is a marvellous service and I have heard few complaints about it. I suggest doctors should be encouraged, over a trial period, to transfer the calls to their surgeries directly to the call centre. I know of some cases where people telephoned their local doctor and got the answering machine, but because of their emergency they were in a state of panic and did not know what to do then. Some of them ended up without getting a doctor, despite it being a serious emergency. There is a case to be made for a call transfer system from doctors' surgeries to the call centre. I am aware this might lead to an increase the number of calls to the call centre and that some of these calls might be unnecessary. Sometimes people ring their GP but when they get the answering machine they do not bother about going further and decide to wait till morning. However, it is a problem for others, particularly older people. I know of one instance where someone died suddenly and when the person calling the doctor got the answer machine he did not know what to do or understand the message on the machine giving him a number to call. Call transfer is something that might be worth considering.

People should be encouraged to become familiar with the doctor on call number. They should have both their GP and the doctor on call number. I am not trying to muddy the waters, but it is a matter of getting used to having both numbers. The service being provided is superb. However, there is an issue of the need for a 24-hour service throughout the country for people with mental problems. Could the call centres be utilised in the future to provide a 24-hour service for people who are potentially suicidal? There seems to be a lack of energy to ensure we have a 24-hour service for people with serious mental problems.

Time is too short to discuss all the issues here, but perhaps the delegation would furnish the committee with information of which it is aware with regard to the difficulty of attracting non-EU doctors to work in the co-operatives, not just the tax issues mentioned by Deputy O'Hanlon, but issues around training and registration in Ireland. The issue arises, not because doctors coming here, in particular those from South Africa, are under-trained. Many of them have vast accident and emergency experience that could be of huge benefit here. There are problems with getting some of these doctors registered and this could create manpower problems for us.

I would like to pick up on a comment made with regard to the cost of triage, which was stated to be approximately €24. However, some €50 is paid to the GP for seeing the patient. Have I missed something here? Is it €24 just to triage the patient?

Mr. Tadhg O’Brien

I will deal with those questions. In response to Deputy O'Hanlon, we were asked by numerous co-ops to look at the PAYE issue, but it is not part of our business. I am aware that the issue is being appealed to the High Court so it is as well for us to keep out of it. It is a tax issue and it is for the companies we pay to pass on the tax. I am not too familiar with the details as we have purposely kept out of it.

We have put significant thought into the issue of transferring calls from GP surgeries. However, it would mean 2,000 phones having to be transferred every night. Instead, we have asked GPs to leave a message informing callers they are off duty and asking them to ring 1850 777911 or whatever the co-op number is. As Senator White said, people need to become familiar with the number. We advertise the service over the Christmas period and we will do that over the coming weeks. Last year we issued fridge magnet cards and arranged for An Post to deliver them in the north east so that people would have the number available. Most of the co-ops have a number that is simple to recall and we will advertise them again in the newspapers.

On mental health issues, while we have mental health services open 24 hours a day around the country, some co-ops have taken on this problem. The HSE intends, in the coming years when funding is available, to use the on-call service for not only mental health services but also for public health, dentistry and so on. That is our strategy under primary care. I will look at the non-EU GP issue.

When we started DDoc we got a bed from CareDoc at a cost of €1 million to triage for the year, in the expectation of a high level of calls but the uptake in calls in the initial year was very low, working out at €24 per triage whereas normal nurse triaging around the rest of the country is approximately €4 per call. The GP STC costs approximately €60. We are retendering the triage service for north Dublin to bring it back in line with the rest of the country.

Thank you. What the representatives have told the committee has been very informative. It might be useful for the committee, after Christmas, to hear directly from some of the co-operatives on their experiences and plans for developing the service. If there is any further information that members have sought that can be supplied to the committee, we would be happy to receive it.

Sitting suspended at 3.32 p.m. and resumed at 3.35 p.m.