Health (Provision of General Practitioner Services) Bill 2011: Second Stage

Question proposed: "That the Bill be now read a Second Time."

I am pleased to have the opportunity to address the Seanad on Second Stage of the Health (Provision of General Practitioner Services) Bill 2011. It is a very important Bill, not purely because it is a matter for the troika and one of the things it was concerned about. It is an issue for me as Minister for Health to ensure that, at a time when we have a manpower crisis in general practice, we do not have any impediment to young general practitioners who are suitably qualified or those who might wish to return from abroad achieving their goal of delivering care to patients in this country. If one is prohibited from treating 40% of the population or more in a given area it is a real problem and a disincentive.

The Bill provides for the elimination of restrictions on GPs wishing to obtain contracts to treat public patients under the general medical services scheme by opening up access to GMS contracts to all fully qualified and vocationally trained GPs. There will be no limits on the number of contractors, which is important. The new changes are being introduced on foot of the commitment to the EU-IMF programme which requires the introduction of legislative changes to remove restrictions to trade and competition in sheltered sectors, including eliminating restrictions on GPs wishing to treat public patients. As I have already pointed out, whether that requirement was there this Bill would have come to pass.

GPs can now only obtain GMS contracts in restricted circumstances as follows: where a vacancy arises due to the retirement, resignation or death of an existing GMS doctor; a new GMS panel is created in response to an identified need for an additional doctor in an area; or where a GMS doctor obtains approval from HSE for the creation of an assistant with a view to partnership within his or her practice. The HSE is currently required before filling a vacant GMS panel or creating a new panel to take account of the potential viability of the panel being established and the viability of existing GP practices in the area. When we are trying to create open competition, that is contrary to that principle.

These arrangements have prevented many young highly qualified and trained GPs from obtaining a GMS contract early in their careers. The current system allows them to treat private patients but they are not able to treat medical card or GP visit card patients until such time as they obtain a contract from HSE. They may have to wait several years for such an opportunity to present itself. This creates an additional difficulty in that somebody who has been in private practice for a number of years — a situation which is prevalent due to the current economic downturn — have had patients who have been with him or her for a considerable length of time and have developed good relationships with them. Some patients may find they no longer have a job and have to seek medical cards which results in having to change doctors. It is bad enough that people have suffered from losing their jobs, with all that means, but they also have to change from a doctor with which they have a trusting relationship.

In addition to the above, two other categories of GPs have certain restrictions placed on their rights to take on and-or retain GMS patients under the current arrangements. These are GPs who hold GMS contracts on foot of interim entry provisions put in place in 2009 where they would have to wait until 2013 before treating any medical card or GP visit card patient, and certain GPs involved in partnerships which have been dissolved or terminated before a specified period would not be allowed to retain patients under their GMS list at the time of the dissolution of a partnership. The Bill will remove these restrictions, which is only proper, right and fair.

When this Bill is enacted, new GMS contract holders will be free to establish a practice in the location of their choice. However, a contract holder approved by the HSE in an area and who wishes to move location may only do so with the prior approval of the HSE. This is designed to ensure continuity of care for patients. Nothing in the Bill prevents the Department pursuing its policy of ensuring proper provision in areas that may otherwise be unattractive.

We are aware that there is no general practitioner available in certain parts of Dublin, areas where there is very reduced availability and some rural areas with availability problems. It is these areas that we seek to support though various grants and aids. We do not want circumstances in which five new practices spring up on Grafton Street, each supported by public money. We are allowing and encouraging open competition and if people want this, it is fine, but we have a duty of care to people who find it difficult to access general practitioners because their areas are unattractive for various reasons. We need to put in place incentives to address that.

Section 1 provides for the definition of certain terms used in the Bill. Section 2 provides that the HSE will be entitled to enter into a GMS contract with any suitably qualified and vocationally trained GP and it will not be limited to granting contracts where a GMS contract holder dies, retires or resigns from the GMS.

Section 3 provides that a GP holding a GMS contract will be entitled to accept onto his list any patient nominating him as his doctor of choice, subject to existing rules relating to panel size. This reflects the original intention of the scheme; it was a choice-of-doctor scheme. If, because of the current restrictions, choice is not available to people — they may have been with a GP and now find they must get a medical card — it is clearly not for the good. This Bill will address that issue.

These rules stipulate that the total number of GMS patients who may be placed on a GP's list shall not exceed 2,000 save where the HSE or such organisation as follows it, in exceptional circumstances, decides to apply a higher limit. This will ensure that GPs who hold a GMS contract on foot of interim entry provisions put in place in 2009 will, from the date this legislation is commenced, be able to take any medical card or GP visit card patient onto their list and they will not have to wait for two more years before doing so.

Section 4 provides that when a partnership dissolves, a GP who wishes to continue participating in the GMS scheme may retain the patients on his or her GMS list on the date the partnership dissolves or terminates, unless the HSE is advised that any such patient does not want to remain on that list. Section 5 provides that the HSE, when filling or creating a GP position, will not take account of the short-term or long-term economic viability of that or other GP practices. This is important because it is not for us to determine the market. The provision will address a recommendation in the Competition Authority's report of July 2010 on general medical practitioners, which was aimed at increasing competition within the GMS scheme.

Section 6 provides that where a GP has been approved by the HSE to provide GMS services at a particular premises, he or she cannot provide such services at another premises unless he or she has submitted a request to the HSE and the HSE has given its consent. Therefore, a contract holder who wants to change his or her centre of practice can only do so with the prior approval of the HSE.

Section 7 provides that when this Bill is enacted, nothing in the Act will affect the operation of the GMS scheme other than the provisions set out in sections 2 to 6 of the Act. Section 8 provides for the Short Title and commencement of the Act.

A key commitment of the programme for Government and a fundamental element of the health reform process involves significant strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. This commitment will be achieved on a phased basis to allow for the recruitment of additional doctors, nurses and other primary care professionals. Access to primary care without fees will be extended on a phased basis over the life of the Government. Initially, free GP cover will be extended to persons in receipt of drugs and medicines under the long-term illness scheme. Primary legislation is required to give effect to this commitment. It is expected that the new arrangements will be in place by this summer. There will be announcement in due course on the commencement date for this arrangement.

The introduction of universal primary care will allow us to move away from the old hospital-centred model, in respect of which health care was episodic, reactive and fragmented, and to deliver a more proactive, joined-up approach to the management of the nation's health. By that, I mean it will become the focus of the primary care position to keep people well and engage in prevention and the monitoring of chronic illness so people will avoid complications and not end up in hospital, have a better quality of life and save the taxpayer considerable sums. It is a win-win for everybody.

I am confident that the Health (Provision of General Practitioner Services) Bill 2011 will contribute to this commitment as it will encourage more young GPs to remain and establish their practices in Ireland. It will make it more attractive for GPs to move here from overseas. There are many Irish graduates abroad who would like to come home but who have found it difficult to do so. The legislation will encourage competition among GPs at a time when many fee-paying patients have less money at their disposal.

This Bill will result in medical card and GP visit card patients having a greater choice under the GMS scheme. It will also help to ensure that private patients of new GP contract holders who qualify for a medical card or GP visit card will not have to change their GP. I commend it to the House and look forward to hearing the views of members.

As always, I welcome the Minister to the House. He has a very difficult job. He is very busy and we are glad to see him here in person. That is not to say his Ministers of State are not very welcome here.

Fianna Fáil, as the Minister will have heard from Deputy Kelleher in the Dáil, welcomes this Bill in principle and would like to assist in improving it on Committee Stage, if possible. While none of us welcomes our having to deal with the troika and the IMF, in a strange way this Bill represents a positive consequence of their involvement. It represents a deregulatory task that should have been done quite some time ago. Everybody who qualified as a GP should be allowed to make himself or herself available for practice, particularly at a time when there are shortages in parts of the country, as the Minister rightly stated, in the provision of care.

I wish to make a point on the availability of GPs that is not related to this Bill. It concerns the points required to enter medicine courses. In another debate, during which the Minister may have been present, I said that while I had no doubt the he received top marks in all his subjects, many of his colleagues, who are very fine GPs and medical practitioners, were not required to get straight A's in all the various subjects required to enter the Royal College of Surgeons or other medical colleges. Let me outline the case of a particular GP, on whom I will not give too much information for fear Members may know who I am speaking about. In the 1960s, when replying to a newspaper advertisement seeking students for the Royal College of Surgeons, whose entry criteria required one to have passed one's leaving certificate and to have two languages, he put down Irish as the native language and English as the foreign language. The individual in question is happily practising as an excellent GP to this day.

I am not saying we should be flippant about the level of attainment required to enter medical school but that we should be non-elitist — more so than in recent decades — in encouraging people. People who are probably more suited to being librarians are encouraged, through peer pressure, to study medicine if they happen to earn the requisite number of points. We need to focus more on who we encourage to enter the profession and be less rigid in requiring straight A's. I would like the Minister to reflect on this in his ongoing work.

While there is no doubt that the Bill will have positive implications owing to deregulation, it poses questions. I do not see any provision that will ensure GPs will want to go to non-affluent areas, nor do I see a provision to discourage those currently in non-affluent areas from transferring, albeit with HSE permission, to an area that they want to be in and which may be a little better. There is no provision to ensure out-of-hours cover to the extent required nationally. I fully agree with the Minister that we ought to move away from resorting to the hospital or intensive care when there is a basic concern and that the system should be much more GP focused.

We want to move away from a position where people automatically think of hospital or intensive care when there is a basic concern. The system should be much more GP-focused. However, very often GPs have not made themselves available for this. Most of the general practitioners I know start at 10 a.m. on a Monday, stop for lunch for a couple of hours, finish at 5 p.m. and have their on-call periods. Almost all of them golf either on Wednesday afternoons or another afternoon during the week. That is the case. The Minister is shaking his head. I would love to do an analysis of the golf courses of Ireland in about 90 minutes' time and count how many GPs are out playing on Wednesdays. I can assure the Minister there are quite a few. There are very few professions that provide for that but I am afraid this one does. That is something we must deal with. One could follow it with the number of hours during which certain consultants make themselves available. That is a challenge for us to change.

In any case, I do not see how this legislation will help with pricing. General practitioners charge what they charge throughout the country and we do not have price caps unless the Minister were so to direct. Obviously, there has been a 15% reduction in terms of GMS payments to doctors. Who negotiates for doctors now? Under competition law the IMO does not. Rephrasing what the Americans said famously about Europe, when one wants to speak to GPs who does one speak to, if not the IMO? According to the competition authorities it is not to the union, so where is the line of communication? How can we get across to doctors they need to start taking on board some of the points we mentioned, from pricing, to availability, to out-of-hours access, and the non-gin and tonic belt locations which some doctors may not care to cover but which need to be covered?

There are positives here but many questions have been raised as well and we will try to assist on Committee Stage.

In the context of services throughout the country the equality of access issue is one that is very close to my heart, as the Minister knows. I would not be true to myself if I did not use this opportunity to ask about this, in the context of the HSE and the very admirable policy of trying to match up with international best practice across the various disciplines. We have had the national cancer control programme, which many people are very happy with, in spite of everything. Professor Kieran Daly is implementing reforms in the area of stenting. The Minister and I have corresponded about the recommendations implemented by Professor Daly that are associated with improving cardiology. My concern is that, statistically, 80% of the people of the country have this care, within whatever the reach may be. However, as the Minister knows well, in the north west of the country the national cancer control programme does not cater for equality of access. In spite of the Minister's announcements in the House regarding follow-up mammography at Sligo General Hospital this still has not happened.

There is also another scenario. International best practice claims that if one has a heart attack it is necessary to insert a stent within 90 minutes. We are implementing a programme of reforms to match up to that standard yet, by the admission of both the Minister and the HSE, this does not take account of the north west of the country on the basis that only 20% of the country's population is involved. The people in that region can be treated for thrombosis because that is the best we can do. In essence, what is meant is that the people of the north west can either move closer or they can die. They will have less likelihood of survival than the rest of the country which has proximity, in cancer to the national cancer control programme with its eight centres, in radiotherapy and in other treatments that are available. In terms of cardiology and stenting the people of the north west must survive on thrombosis treatment.

I welcome the Bill but while we are all striving to make greater equality of access and cheaper treatment for all the people of the country in terms of GP care — never mind who is in government — is there a HSE policy to match international best practice across disciplines? It still uses the excuse that 80% of the people are covered so the people of the north west, who have very particular geographical and proximity concerns, can sing for it. If we hide under the cloak of lack of resources and everything else, we will not do it. I would like to hear the Minister's views on this issue.

I welcome the Minister to the House. I also welcome the students who have joined us in the Visitors Gallery. I hope the debate relates to their careers and that in the not too distant future we will see some of them as part of the medical profession here, able to practise in this country.

This new Bill gives the right to practise to those who meet the required criteria. The restrictions that were there previously did not comply in real terms with EU regulations. I was surprised and mesmerised that nobody had ever challenged them because they were anti-competitive. I took out the 1996 circular issued in respect of this entire issue which set out how people were to be appointed. This was an amendment to earlier regulations and I am sure it, too, was amended since 1996. The criteria as set out allow for the provision of a proper level of access to general practitioner services for patients. They state patients should have a reasonable degree of choice in selecting a practitioner and that due regard is given to the question of viability of practice in the area in question. Viability of practice, therefore, was one of the criteria in deciding whether an appointment should be made.

It was interesting to look at the appendix 4 regulations on deciding whether a person should open a practice. These examined the number of GMS patients on the list, the age and gender profile of the patients, the geographic area in which the practice is situated, the number and age profile of GMS doctors in the area and their list sizes. Also included were the private practice profile of the area in question, including the ratio of private to public patients, the population size of the area and surrounding areas and the factors advanced by the applicant doctor in support of his or her application. Although many issues were taken on board there was not the freedom for a person to come in and open up a practice. Applicants could open up and be involved in private practice but they were not entitled to take on people with medical or GP cards. This new Bill allows the whole area to open up and I welcome it.

There is another issue which I have raised previously. Although we are allowing new people to come onto the system there is a need to move forward in regard to computerisation. I raised the issue of the system in Denmark where a person has a patient medication card just as each one of us has a Visa card. This can access one's bank account no matter where one goes. Likewise we should be working towards a system where every person would have a patient medication card. I realise this is being rolled out in cancer services but it is a long-term agenda. The person would go to the GP, present the card, the GP would provide a prescription, not by hand but by putting it onto the person's file. The patient could then go to the pharmacy, present the card and the pharmacist would access the information on the file. If the person is admitted suddenly to hospital all his or her medical records are on the card so a doctor in the hospital need not wait for four or five hours for that file because it is immediately available. Obviously, there must be security provisions but this is the way forward. When we encourage people to start up in this area we must ensure we also encourage computerisation in order to cut down the paper load involved in medical care.

It was interesting to look at the figures in regard to medical cards and see how the number of people with cards is growing. As of 1 January there were 1,694,063 people with medical cards and another 125,000 who had GP visit cards. A total of 1,819,720 people are entitled to medical care. We are moving close to a situation where almost 40% of the population will have either a medical card or a GP card. This emphasises the need for opening up this entire area and allowing more people into practice.

The figure I have for the number of GPs registered under the GMS scheme is 2,279. In real terms this is rather small when one thinks of the number of people with medical cards. I realise some of the practices in question would have more than one doctor but it is interesting that the number of card holders has grown in the past two or three years and will probably continue to grow in the coming years. It is important that the standard of care is maintained. This is one of the issues on which we must continue to improve. I know people can be critical of the services provided but the majority of GPs provide an excellent service and system of cover. However, there are deficiencies in some areas of which we need to be conscious. As the primary care reimbursement scheme comes to €493 million a year, it is important we get value for money from it.

I have concerns about GP training. A training doctor at a hospital I know told me a young trainee inquired why he had to learn about stitching, a relatively small procedure, or work on weekends as he would never have to do these as a GP. There is a culture in general practice that it is a nine to five, five days a week job. It is necessary to get it across that a community GP scheme must be comprehensive — people do not get sick just between nine and five — and not depend on which part of the country or an urban area one resides.

I agree with the Minister's point during the Dáil debate on the legislation on the need for GPs to work together to provide a comprehensive service across a range of areas. He referred to a practice in Mallow where 17 GPs have come together to provide much more services than before at a local level.

I know of several GPs who trained for several years to be paediatricians, obstetricians and gynaecologists but did not finish their training. They have a wealth of experience which should be tapped into for the benefit of hospitals which may require temporary cover, say for a day.

I welcome this long overdue Bill which will provide a degree of competition in the GP sector and enable us to provide a comprehensive health service in communities.

I welcome the Minister to the House. I also welcome his presence in the Department as he brings to it the zeal of a reformer, something sadly overdue in the health service. We look forward to supporting him in his efforts to forge real reform.

I welcome this important Bill because there was a problem with the structures for entrance into general practice which was having negative downstream effects on the service delivered to patients. This legislation will remedy this and increase the ease with which suitably trained and experienced doctors can get access to general practice. It will also improve the access of patients to highly qualified general practitioners. There are several demographic trends which suggest we could run into a serious shortage of GPs in the future. Even if that were not to occur, it is natural justice that these reforms should take place.

Ireland has the lowest number of general practitioners per head of population of any western country. In general, a low number of GPs per head of population means either the country has an underdeveloped health service or there has been a subtle internal professional rebalancing between primary and secondary care as happened in the US, which has a relatively low number of general practitioners but a large number of specialists. People in the States tend often to go directly to specialists or other physicians and surgeons when they have medical problems. In Europe, we tend to go a general practitioner first. When one looks at the global figures of GPs per head of population, one will note those countries which follow the more liberal Bismarckian welfare system model tend to have relatively large numbers of GPs. The NHS model is anchored near the bottom while its "Mini-Me", the New Zealand health service which apes the NHS so flatteringly, is even lower. Then at the bottom are ourselves. This reforming legislation will go some way in fixing that.

We should reflect on the differences we have in this country between general and specialist practice. We have a much more functional general practice system with only one problem — the bottleneck at entry of new GPs into the system. When that bottleneck is lifted, we will see the full flowering of a good general practice system.

I have minor quibbles with the way GPs are trained. In my ideal world, the ludicrous division between hospital-based doctors and GPs would be done away with. Having a highly experienced GP sending a patient to hospital to have an opinion given by a trainee doctor is crazy. Our GPs should be fully integrated into the hospital community, admitting patients to hospitals and doing rounds on their own patients. GPs should be more like the American internalist. While this is not the forum for a debate on the minutiae of how GPs are trained, I would see a certain logic to having general practice slightly split between adult and paediatric practice and a cohort of hybrids between adult general practitioners and internal medicine physicians who would have a practice which would be largely ambulatory and domiciliary but have a hospital basis.

The greatest difference that stands out in our general practice service model is that while GPs are paid two different ways for the patients they see, general practice care is single tier. Public and private patients will attend the same practices during the same times, sitting in the same waiting rooms. There are not separate times for private and public patients. The magnitude of reforming the health system is not that large and can be done because it has been partly done in general practice already.

One key issue which I believe the Minister will safeguard during his long tenure unless he gets promoted——

Yes. General practice in Ireland answers to the principles of social democracy but is not intensely bureaucratised. General practitioners run their own practices, get paid by the Government for their public patients and answer to the various agencies of the Government and their profession for the standards which they bring. This is vastly different from the way we run the hospital system. Hospital-based specialists work for a cohort of professional managerialists in heavily bureaucratised institutions. I wish the Minister well with this legislation and the rest of his reforms.

I welcome the Minister to House. This welcome legislation is simple and self-explanatory, giving greater choice to people and leading to greater competition in the general practice market. Hopefully, it will limit the emigration of our trained GPs and even facilitate the return of those who had to emigrate in the past. As Senator MacSharry noted, other measures could also be considered, whether in the context of this Bill or through other legislation, to deal with the pricing system operated by some GPs. Prices should be built into GPs' contracts with the HSE. As they are already well paid for medical card patients, they should not be allowed to charge a further €50 to write a letter in order that a patient can apply for a medical card. This practice should be outlawed under the legislation.

It is scandalous that somebody in receipt of disability benefit who requires a doctor's certificate on a weekly basis might have to pay €30 for it. People should not have to pay for this service if they are patients of the doctor concerned. Similarly, medical card patients should not have to pay extra to have their bloods taken. The practice that the Minister described as having the shoe box on the table should also be outlawed. Elderly people should not feel obliged to give their doctors additional money to get better care. If they want to give the money to the Department of Health, we could put it to better use than giving it to well paid GPs.

I acknowledge that the Minister is not to blame for the management of medical card system by the primary care reimbursement service, PCRS. More than 12 months ago I warned that the change to the medical card system would be a disaster. The issue has been raised with the Minister on previous occasions but, unfortunately, he has accepted the assurance from the PCRS that 85% of medical cards are being dealt with the normal way. I know for a fact this is not true, however, and I could set out any amount of examples to support my contention. I invite the Minister to come to my office and listen on speaker phone when I eventually get through to the PCRS to ask about five different cases. The bottom line is that it appears to be losing applications. If a medical card application is straightforward there is no problem but even one complication creates problems because the PCRS will write back to the applicant after two weeks to request further information or admit to losing something. In one case, an application was submitted on 25 September and the PCRS wrote to the family concerned to say it lost the husband's payslip. I have been in regular contact with the PCRS in the past three weeks because it cannot find any information pertaining to the file but it asked us to resubmit the entire application. This example is repeated on a daily basis. I do not know what it is telling the Minister but it has a huge problem on its hands.

Since it took over the control of medical cards, its approach has differed from that of the HSE. For example, an applicant aged between 16 and 25 years who lives at home is only issued with a medical card if his or her parents also have one. That was never the case previously. The guidelines for medical cards set out an income threshold of €164 for those who live with their families. I have it on the highest authority that PCRS is wrong in its interpretation but it is not for changing. To offer another example, people who have a right to medical cards by virtue of being on community employment or rural social schemes are being told their families have to be means tested.

The guidelines for medical cards were last updated in 2005 or 2006. I suggest that they need to be brought into line with social welfare rates. Anybody on the baseline of social welfare is barely above the poverty line and the medical card guidelines set out incomes that are far below the poverty line.

The Minister referred to the long-term illness scheme but I missed what he said. He has included other long-term illnesses in the scheme. Are cancer patients among the categories of people who will be considered for a long-term illness book?

Senator MacSharry referred to the out-of-hours doctor service. This service is not working. Doctors used to work on the basis of a rota system so that a local GP was always on-call at weekends. Given that we are about to open up to competition and increase the number of GPs in the market, perhaps it is time to reconsider a rota system because the new GPs might be delighted to work weekends and be on the golf course on a Wednesday afternoon.

In regard to protection for GPs based on the potential viability of their practices, newspaper reports of earnings of €600,000 and €800,000 from the GMS scheme suggest there is room for more GPs. It is said that one never sees a bookie going out of business. I never saw a GP going out of business.

I welcome the Bill and endorse what Senators MacSharry, Colm Burke, Crown and Kelly have said. The Bill has been recommended by the troika. When the troika visited Trinity College at 9 a.m. on a Monday morning — we tried to notify as many Senators as possible — one of its members suggested that the GP fee in Ireland is twice what he pays in Brussels. This costly system we are now dismantling. Incumbents generally dislike competition and they tend to lobby Governments to protect their privileges. As Senator Colm Burke pointed out, some of that lobbying turned what the Minister described as a choice of doctor scheme into a highly restricted choice of doctor scheme that would not have received the approval of the Competition Authority.

We should wait to see how the restrictions on locality and the decision making on the viability of practices operate in practice. We may find that new GPs will locate in areas that are not well served at present. The two occupations are not comparable but under the judgment of Mr. Justice Roderick Murphy on taxi deregulation, operators are entitled to enter a sector once they possess the necessary skills and training and the public is entitled to the services of such persons. The biggest increases in the opened up taxi market occurred outside Dublin. New producers can do lots of things when the market is not restricted. As we have 24-hour shops and petrol stations, we should also have 24-hour GP clinics. The open market will facilitate that. If certain kinds of GPs are needed in Temple Bar and other areas which are mainly frequented at night, a service will be established to deal with whatever medical needs arise. The golfing world that Senator MacSharry mentioned was too comfortable. The new people will follow where the need for their services exists.

I hope there will be a big reduction in the cost to the taxpayer because one hears already of examples from Killarney that where extra doctors move in the cost is being reduced. We should look for that also. At the end the Minister mentioned the budgetary implications, which could be very positive if the Department can negotiate at the new rates that will be available when all these extra people enter the market.

At a seminar organised by Pfizer approximately a year and a half ago when the Minister was the Opposition spokesperson and I was just an ordinary economist in Trinity College, we discussed the deskilling of GPs. Is a GP just to be a person who writes a letter to employers stating that an employee is sick when all three parties to the transaction know he is not sick, writes letters to pharmacists called prescriptions and writes letters to consultants called referrals? As Senator Crown has said even a highly experienced GP might send a letter to a relatively junior person in a hospital. We should try to relocate many of the functions of medicine away from outpatients, where I gather 95% of patients are never admitted and the cost is two or three times the cost of going to a GP, and certainly away from inpatients where costs of approximately €1,000 are run up. If we can put the GP at the centre, as the Minister intends, there are substantial possibilities.

I favour not just competition among GPs but also among health insurance companies. I was hoping that competing health insurance companies would be able to state they did not cheat by taking on only young people, but got better deals. This brings me to the Milliman report, which I am sure the Leader has discussed with the Minister. While we could have a separate debate on that report, it refers to patients being kept in hospital for 10.6 days for a procedure which should take 3.7 days in an alternative system and accumulates an enormous cost for the State.

The health service doubled its staff between the mid-1980s and 2007 when it peaked at 110,000 people. There has been too much bellyaching about a 2% or 3% reduction now. The real question is how it got from 55,000 people to 110,000 before this problem was finally addressed in 2007.

Regarding means testing, in his book, Professor Drumm states his hope that by centralising medical card administration it could be done by 130 staff as opposed to by 430 when it was done in separate offices. Given the failure of the Department of Social Protection and the Revenue Commissioners to get their act together on pensions, should all means testing not be done in one central location rather than having means testing in multiple locations? With higher education grants it is extremely strange how easy it is for the self-employed to get student grants and virtually impossible for PAYE people to get them. Means testing and medical cards are part of a wider problem. Some GPs were required to wait until 2013 before treating any medical card patient and I am glad the Minister has done away with that.

The change in rules on admission to medical schools makes it more difficult for women in particular to study medicine. In our college we have people with the maximum 600 points from their leaving certificate examinations who, because of the HPAT could not have gained entry. Looking back on that, if all the people with high points — 500 or more — who had applied to study medicine had been allowed in, we would have a far better health service today. Keeping out talented young people from being GPs — which the Minister is correcting with the Bill before us — or from the study of medicine is not a good idea in terms of the health service we are trying to build up.

This is a great start and should lead to the development of group GP practices and transferring outpatient and even some in-hospital treatments to GP surgeries. The Bill represents a start and has already been commended by people from all sides of the House. Based on the economics of it, it seems to be the correct way to go and I compliment the Minister on the Bill.

It is great to have the Minister here. Rarely have I received so much support for a Bill, obviously from GPs who are trying to access the GMS list, but also from patients. It is difficult to think of another Act of the Oireachtas that would have such an immediate positive impact on the lives of so many people once passed into law. Is it not great to see such cross-party support on all sides of the House? Thousands of patients are waiting on the passage of this Bill in order to access medical services. I obviously support the Bill and would like to see it passed speedily to give all fully qualified GPs access to the GMS list.

I was struck by the story of a qualified GP who has been qualified for 20 years. She worked in Blanchardstown as a GP in the GMS. As her husband's job was decentralised to Galway, she was obliged to resign her post for family reasons and has since been unable to see GMS patients because of the inequity of the system up to now. She has worked on and off for other GPs and in the hospice in Galway. Approximately a year ago she opened her own practice. She has many patients calling every day asking when she will be able to sign them up. She has said that some are forced to pay to see her even though it is not financially easy for them to do so in order to attend their doctor of choice. A right is being taken away from patients and it is wrong to turn patients away. So we see value in the Bill for that reason.

The Bill is definitely a step forward in the provision of good primary care services close to the patient's home and it offers a level playing pitch to all GPs. It is also welcome for younger doctors who can now see a career path and will be less likely to emigrate having been educated at the expense of the taxpayer. I am familiar with a young doctor who has been abroad and acquired considerable expertise. He came home and did his best to access the list. When he could not do that, he left a year ago. He gained expertise from conflict situations and had great zeal and a sense of social justice. Those are the values we should be espousing.

The Bill also offers a great return for the taxpayer and is one of the most impressive results of the requirements of the EU-IMF deal. How many of us can stand up here and say we are absolutely delighted with everything the EU and the IMF want? I cannot say that, but I am impressed by this. It was meant to be passed in the third quarter of 2011 and we need to implement it without delay for the sake of everybody. How does the Minister believe the Bill will feed into our vision of universal health care and primary care centres?

I also support the Bill and along with many doctors in my constituency I urge its passage as soon as possible. Given that we have rushed legislation on many items, I wonder why this is not being rushed. With so much apparent unanimity we could probably have completed Committee and Remaining Stages today to allow the Minister to enact it with his order. As Senator Healy Eames said, the Bill arises from the EU-IMF agreement, but it was contained in the previous Government's national recovery plan which the IMF and EU agreed to bankroll. This was a long-standing policy that Fianna Fáil wanted to introduce and it needs to be enacted as soon as possible.

I seek clarity. Under the provisions of the Bill is the HSE obliged to hand out a contract or is it just entitled to hand out a contract? Are all GPs who open a practice entitled to get a contract or is it just that the HSE is entitled to give them a contract?

As the Minister is in the Chamber, it would be remiss of me not to mention that today is the first anniversary of a promise Fine Gael gave on the regional hospital in the north east. The five candidates, four of whom are now Deputies, announced to the local newspaper that along with the Minister they had met investors who were prepared to build a regional hospital for the north east and that it would be completed within five years. The public private partnership model had been agreed and Fine Gael had pledged the money. The Minister should not shake his head because this was reported inThe Meath Chronicle exactly a year ago with his name attached to it.

The newspaper of record. Go on.

I am sorry, Minister. The record was of the five Fine Gael candidates at the time and the now four Deputies——

Show me where I said it.

They made a statement to the effect that investors in a hospital project met the Minister and that these investors would build it within five years. This was to be done and it was manna for the people of Meath. They are waiting for the hospital. Money was not a problem because, according to Deputy Damien English as recently as three weeks ago, it was arranged to be a public private partnership and the Government would have to pay only €40 million per annum to get it up and running. This was all arranged. The Minister has given replies to parliamentary questions from several Deputies on this issue to the effect that he knows nothing of these initiatives. Is it appropriate candidates should meet investors in respect of this matter which is a decision of the HSE and the Department of Health? Is the Minister involved in the negotiations? Are these negotiations real? Are they taking place or is it simply a bluff by the Deputies?

According to the replies, the Minister and the HSE appear to know nothing about it. What is the status of the hospital? My Government's position was clear enough. We were keen to build it but there was a lack of finance. If the Minister states that there is a lack of finance we will understand, save to say that the pressure is considerable. However, it appears there was no lack of finance on 9 February 2011 because the four candidates, now Deputies, stood up and suggested as much to everyone at the time in light of the IMF agreement, the publicly available tax receipts and the briefings given to Ministers about the state of the country's finances. They said the State did not have enough money but that they had met investors who would pay for it and that the State would only have to pay so much every year. I am unsure whether the Minister is aware of "The Simpsons" but it reminds me of the monorail project in "The Simpsons" where investors came in and built a massive project. That got the go-ahead and this did not so they are one step ahead of us. What exactly is its status? What is the status of the regional hospital for the north east in respect of which one year ago investors met the Minister's colleagues and they had all agreed that it would be built within five years? The Minister's name was attached to it. If that was simply a bluff, then it was a wrong bluff because we are dealing with people's lives and health. It is a bluff that continues because we met the Deputies only three or four weeks ago and they continued with this. They said their meetings continued with investors but at the same time the Minister and the HSE appear not to know the first thing about it. Let us have a clear and honest answer because the people of Meath seek clarity on it.

I am pleased to have a brief opportunity to speak on this important Bill, which I welcome. It is a positive step. The reports of the Competition Authority and the National Competitiveness Council consistently refer to the need to open up what are termed the "sheltered professions". This includes the legal profession and the process is under way there. Restricted access to the pharmacist profession was mentioned previously and it has been removed somewhat. The dental profession was mentioned in terms of displaying and advertising prices. This has taken place. Now, the general practitioner profession, perceived to be a closed shop in many areas, is being opened up. The Minister has made a statement to that effect.

It is remarkable that the HSE was in a position to judge whether a practice was viable or whether it was in the wrong area or whether it should not have been in a given place. Now, if patients have a medical card or a GP card, they can go to the GP practice of their choice. This is a positive thing. Competition is about letting the market find its level. If one wishes to open up a sweet shop that is one's own business. One does it where one wishes and if one provides a good service and a price that attracts customers, one will do well. This is what we have in this Bill as well. However, certain standards and regulations will be required for the medical profession and we all accept as much. This is an important step in developing the primary care focus that the Minister is intent on attaining. It is a central plank of the Minister's policy.

Some GPs in the Cork area have come together to combine their practices. I have in mind one practice in particular in which nine GPs in the area have come together to provide a service. They brought their patients with them and a pharmacist has been attracted to the area as well. This is working well for the community and it allows the additional services such as physiotherapy, psychology, chiropody and so on to prosper. All of these services are attracted to the investment and the venture is providing a good service in the area.

It was stated that some GPs play golf on a Wednesday afternoon. Any of those GPs could run evening clinics from Monday to Friday and on Saturday morning. It is up to them how they spend their time and provide the service to their community. One would probably find that there are many options in the area where they work and it suits their clients to have a GP service available in the evening time and on Saturday mornings. For those working as GPs, income is based on the number of patients they see. Therefore, the harder one works, the more money one makes. However, we need competition in the area of fees.

Lists are produced annually of the amount of funding paid to individuals under the general medical services scheme. We should take a step back from these lists before examining them and one might find that one individual is named but there may be many doctors in the named practice. As usual there are always statistics and information but it depends on the aspect from which one wishes to examine them.

The most important thing about the Bill is that it sends out a message to young doctors or doctors who have gone abroad to the effect that there are opportunities for them if they have the energy and commitment to provide a service in the country. If one wishes to come here, there are opportunities and they can do it if they give it the time and the service. Individuals will always respond to service. Price may be the main element but service is an important part of it too. Consumers and patients respond well to it. This is an important signal and one of the more positive aspects of the EU-IMF agreement. The Competition Authority will be relieved that we have finally adopted one of the major policy recommendations it has sought for years.

I welcome the Minister to the House and the publication of the Bill, which I support. I fully support the Bill and hope we will see its speedy passage through this House and through the Dáil. I will desist from raising local health issues but I call on the Minister and the Leader to arrange for the Minister to come back to the House to discuss the national health service plan. There was a debate on it in the Dáil. We will see the publication of regional plans and local hospital plans in the coming weeks as well. This serves as a good opportunity for the Minister to come back to the House to discuss these issues as well as the whole area of primary health care.

I am very much in favour of primary health care. There are many examples, such as that in Cork outlined by the previous speaker. However, there are many examples of private world-class primary health care centres. There are several in Waterford city and county in which there is an integration of GPs, physiotherapists, dietitians and weight management professionals. There are pharmacies on site and minor medical procedures are carried out. A network of world-class primary health care centres can take the pressure off our acute services. They also specialise in preventive medicine. There is a need for a reorientation of funding in respect of how we support, see and value primary health care. I hope the Minister can return to the House at some point to discuss the issue.

A previous Senator raised the issue of medical cards because we are discussing the GMS system. During a previous visit to the House the Minister stated that there was a short turnaround time for people applying for and receiving a medical card. However, our experience is to the contrary. I will not go back over the points as they have been well made by a previous Senator. However, I hope the Minister will examine the matter because, unfortunately, this is causing a major problem for people throughout the country. We are all keen to ensure that people get the medical card as quickly as possible to avoid confusion.

There is no question but that this Bill must be put in place. While several Senators have referred to the troika's motivation, it differs from mine. It has referred to increased competition and restrictions to trade. My concern is the provision of and access to proper health care rather than a monetary concern, although economics are also important.

We have to pay the bill.

Of course we must pay the bill, but health care should not be about profit. That is the point.

The Senator is on both sides.

Senator Cullinane to continue, without interruption, please. Senator Healy Eames already had her opportunity to contribute.

Health care should not be based on profit or, at least, access to health care should not be based on ability to pay, but on need. This is a fundamental principle I hold. This problem is one of the core difficulties with our primary health care system and it needs to be addressed as part of an overall patient-centred reform and rebuilding of primary care on the basis of need, equity and efficiency.

I hope, like other Senators, this Bill will keep many young GPs in Ireland and, perhaps, increase the number of GPs we have. I assume the Minister would agree that we need a more comprehensive approach to primary care and that the provision of general practitioner services is only one part of solving the problem. Other speakers mentioned the acute shortage of general practitioners here. For example, we have 52 GPs for every 100,000 people, in contrast to other European countries. France, for example, has 164 GPs for the same number, Austria has 144 and Germany has 102. These figures show GPs are under-represented here. It is no surprise that the limited number of GPs is most noticeable in areas of high disadvantage, which highlights the inequalities in our system. For example, Tallaght has 24 GPs for a population of 71,000.

I support the Bill because I want to ensure we have equity in the system and that we support greater numbers of new GPs coming into the system and improve access to it. However, I appeal to the Minister to see this Bill as only one part of the jigsaw in terms of reforming primary health care in this country. I know he has spoken about reform across the board in the context of the HSE, primary health care and acute services, but he should also be aware that many of our acute services the length and breadth of the country are under severe pressure because of cutbacks, the embargo on recruitment and the number of people leaving the public service. As I do not want to raise all of these issues in the context of this Bill, I appeal to the Minister and to the Leader to give us a commitment that the Minister will come back to discuss those issues constructively at another time, because we all have the best interests of the health care system at heart. We may disagree with where money is spent or on policy, but we all want to see the best health care possible provided for the people. On that basis, I hope the Minister gives a commitment to come back to discuss the issues I have not dwelled on today.

I too welcome the Minister to the House and thank him for attending and informing us of what is happening. This is a good Bill and I hope the legislation is introduced at an early date. Allowing more GPs into the general medical card scheme will improve patient access to GPs in rural areas, particularly for patients with medical and GP visit cards. With the introduction of this legislation, GPs will be able to establish practices in locations of their choice. Statistics show that 60% of the population receive GP services on a fee-paying basis and 40% receive such services under the GMS scheme. That 40% is a significant proportion of the population and it is important they have the chance now to shop around.

The enactment of this Bill will satisfy the terms of the EU agreement and will lift the restriction to trade and competition that existed in sheltered sectors. It will also eliminate the restrictions on GPs who wish to treat public patients. The current practices for allowing a GP into the GMS scheme are restrictive and outdated, as GPs can only obtain a position where a vacancy arises due to retirement, resignation or the death of a GMS scheme doctor.

I thank the Minister for being with us and for his work on this Bill, which is a move in the right direction. The Minister may not have this information, but can he let me know whether mammography services will be returned to Sligo General Hospital?

I thank all those Members who have contributed to this debate and thank them for their support. It is not too often we get that level of support for a Bill.

There is no question but that this is an important Bill and I will try to respond to the issues in the order in which they were raised. Senator MacSharry opened the debate and I welcome his support. He remarked that there is no incentive in the Bill to encourage GPs to move into poorer areas. He is correct, but that is not what the Bill is about. The Bill is about ensuring we get the highest number possible of fully qualified GPs available to all of the population. A private patient has a choice of doctor. GMS patients had a choice in theory, but if the doctor chosen was not on the medical card list, the patient would have to pay, which does not represent much of a choice. This Bill corrects this.

I have mentioned that we are focused on ensuring that we address and support general practice in black spots to which it is difficult to attract GPs, such as urban deprived areas and remote rural areas. The Department reserves that right with regard to the supports it will provide. In other words, just because a doctor is given a GMS number, this does not mean he or she will get the full range of other supports that might be available. I do not wish to see a situation where, for example, we are supporting five different practices in Grafton Street. However, if the doctors want to set up there, that is fine. That is what competition is about. We have a social duty to provide primary care facilities, including general practice, to parts of the population that would not be commercially viable from the business point of view and we must honour that duty.

Senator Clune raised the issue of two-hour lunches, golf courses and half days off. I do not hold any candle for general practitioners, but I would not like people to leave this House under the impression that is the norm. In the main, general practitioners work very hard and provide a very good service. There will always be individuals who cause questions to be raised, but the tradition of golfing on a Wednesday was a reflection of the fact that the person was working on Saturday and often had to work over night. I do not agree with having doctors on call 24 hours or with working 36 hours. We do not let truck drivers work those hours and I would not like one of my loved ones to be looked after or for a life or death decision to be made by a doctor who was exhausted, who had been working all night and day and who was expected to work the following day. We are trying to get away from that, which is where group practices come in. We want to encourage group practices so that people can work different shifts.

The issue of pricing is a key part of this Bill. We have seen two new doctors start up in Killarney and they are considerably more competitive than those who are there already. We will see more of this happening. The Department has no role in the setting of private fees, nor have I as Minister. Private fees will become part of history in a few years when we roll out free primary care and GP care throughout the country for all citizens. I take on board the point made by Senator MacSharry on the IMO. I have always maintained that it is easier to deal with just one leader. The Americans ask who they should go to when they want to talk to Europe. I look at the situation in Iraq and see that it is far easier to deal with one leader than with 25 warlords. The IMO still has a key role and it can still discuss many aspects of care and work. However, the Department will retain the right to set the fee and it is in that regard the Competition Authority is concerned.

Senator MacSharry mentioned the issue of coronary stenting in the north west. He is correct. There is an area in the north west where we cannot deliver a similar service to that we deliver throughout the rest of the country. This is an issue I have discussed with the Northern Ireland Health Minister, Mr. Poots, with regard to cross-Border co-operation.

We have had some very good discussions and we are making very good progress, and we have discussed this issue. They were thinking of extending facilities in a hospital and there is not a big need for it. I have spoken about Letterkenny, Altnagelvin and that area, and how we can deliver for both our communities. We are getting on very well in that regard and I look forward to more developments in that area. Not all heart attacks require thrombolysis or stenting but all ST segment elevation heart attacks would need such a procedure, which is a concern.

I worked in Sligo and the north west many moons ago and I was struck by the strength of primary care. As a result of the geographical spread of people, that health board area and subsequently the HSE were very good at supporting primary care general practice. There were many initiatives up there that I never saw in Dublin. That is not to say we do not need to improve, and we will do so.

Senator Burke spoke about the electronic medical record, and his comments are correct. There is much work being done on that currently, with several different options being examined. The one I prefer is held by the patient, and it can be updated on a GP's terminal at any time, as the GP would hold all the information in any event. There could be licensing with regard to tiers of access as, for example, a patient may not want a physiotherapist to know all the detail's of his or her medical care. It may be appropriate in some instances but not in others, but I will not get into examples.

The quality of care is sacrosanct and I will not undermine that concept. The Irish College of General Practitioners and the Irish Medical Organisation, to some extent, have been very good at achieving what we now have in well qualified general practitioners. I do not want to do anything to undermine that quality, and I will not do so. That is why I made it very clear in the Bill that the application is for suitably qualified GPs. This is not open to people who did five years of medicine in a hospital and who then decided they wanted to be a general practitioner. People will require relevant qualifications and training.

Value for money was also mentioned by Senator Burke. Some 120,000 people attend general practitioners every day in this country, with 3,500 per day attending emergency departments. One can imagine what would happen if there was a shift of 1%, as that would lead to a 25% increase in accident and emergency activity; if there was a 5% shift, everything would collapse. The person informing the Senator would be in the minority, and anybody going into general practice should be looking to expand their range of abilities in terms of suturing and working weekends. I do not know of any training course that allows anybody believe they will not have to work weekends or that they should not be able to suture a patient. It is a particular concern for me and I have asked for an audit of out-of-hours services for general practice to see how many people have been referred to hospital who should have been treated by a GP. I get a sense sometimes that doctors on call at night — I should not identify locums in particular — may be less inclined to do that suturing work and it is easier to send a patient to hospital. That is unacceptable. It is an ordinary part of a general practitioners work.

It has been mentioned by others that when a large hospital develops, as it did in Tallaght, there can be gradual deskilling of general practitioners. As the accident and emergency department is so near, people can be inclined to go in that direction and we must ensure we have the correct incentives. I take the point about group practice, which is extremely important not just because of economies of scale and the broader range of services but also because of peer group support and monitoring. There is a bit more safety for patients in that respect.

I called for the following in opposition before I became a Minister and I will see that it happens. HIQA should become involved in inspecting general practices and set standards in them with regard to premises and equipment. The process that is happening in our hospitals must spread across this spectrum. HIQA has a large job of work and we must make priorities with our limited resources but there is a clear plan set out for that.

Senator Crown and others, including Senator Healy Eames, spoke about natural justice and demographics, and I agree with those comments. As some 50% of graduates in general from medical schools go into general practice, we can ask where they are gone, in the same way we ask where the 50% of non-consultant doctors are gone. There is a lack of a career path both in general practice and in hospitals. I have already indicated we would address that and I am examining a report relating to the creation of a consultant grade 1 or specialist grade when a person finishes specialist registrar training. One from four specialist registrars becomes a consultant; all four are fit to be a consultant but we do not have enough jobs. Why not create a clear career path where all four move to a specialist grade and move to become consultants in four or five years? This is not meant to be a graveyard for highly qualified people, as has happened in other jurisdictions, but rather a natural progression.

I will make two important points. If people talk about indenture — holding on to medical students when they become doctors, as the taxpayer has paid for them to become doctors — it would cost approximately €150,000 to train a doctor to just beyond intern level. It would cost nearly €1 million to get them to the position of specialist registrar, and that is when we are saying goodbye to them. That does not make sense. I am sure Senator Crown would not disagree with me in saying that this is the time when many doctors are at their most productive and involved in research. We are sending them away and offering them no opportunity to stay. We could have a win-win scenario with this proposal, and these positions would be clinically autonomous, meaning such specialists would only have to report to a clinical director.

Senator Crown also mentioned primary care and a cost-effective health service, and strong primary care is at the core of the fairest of these systems. America spends more than 16% of its gross national product on health but it has the most inequitable outcomes; if a person is well off, he or she will do well, but if a person is less well off, the outlook is pretty poor. Many people could go bankrupt as a result, and we do not want to see that here. Universal health insurance will address this issue.

As GPs have worked in hospitals, they understand the hospital system to a greater or lesser extent. Many consultants have not worked in general practice and would not understand it at all, which should also be addressed. There should be understanding. Bringing GPs into hospitals to work in areas where they have an interest is an excellent idea and, equally, bringing consultants to the community to deliver care is an even better idea. Why should 30 people have to leave Balbriggan or Oranmore when one person could travel the other way?

There was a comment on the two-tier system. Mr. Dale Tussing, an American economist, considered this when the capitation system was introduced and his fear was that with a two-tier system of payment there might be a two-tier system of care, like there are in hospitals. He remarked in the late 1990s that it had not happened, much to his pleasure and surprise. There are lessons in this respect as the two-tier system might come about in one area but not another. We are looking to address the issue through universal health insurance, where everybody will be a private patient and treated the same. People will not have to worry about whether they can afford care, as that will not be a determinant.

Senator Kelly spoke about private fees for letters and social welfare certs, although such certs should not give rise to fees. The medical card and the primary care reimbursement service is a significant area of contention. I know that when I stood here last I indicated that I had been informed that the process was improving. I accept that did not become the case. Last week I visited the service and met Mr. Burke. I am aware that he apologised on radio for the way things have gone and he has taken a different view. As a result of a request from me he has slowed down the review process to deal with the realities he is facing with regard to the volume of numbers he must deal with.

There is no question about the card of anybody on social welfare. People will keep their card until the review is complete, as opposed to losing a card until the review is complete. In fairness to Mr. Burke, we must all acknowledge that 21,000 people had not responded to contact from the service by the end of January this year. Some 4,000 of those people had not had any activity on their medical card in two years. The service has already tried to contact these people twice and a third letter will be sent. We will have hard individual cases, and there may be people who do not go near a GP because they are so well despite having a medical card. They are few and far between.

How will he behave, and how will the Members of this House and the other House behave, if he is challenged at a meeting of the Committee of Public Accounts by Deputies asking him to explain why doctors received payments in respect of 4,000 people who did not use their cards for two years and did not respond to the letters that were sent to them? He might be expected to explain what sort of probity is involved in that.

There are two sides to this story. It is not simple. We want to ensure those who need medical cards, have medical cards and are entitled to medical cards keep them and are not discommoded. We have put in place several new initiatives to ensure they are not discommoded. There is a probity issue here. We cannot pay doctors for people who are not in the country anymore. That is half the point.

I would like to move on to speak about community employment schemes and the guidelines for the medical card. As I have said, we are moving in a determined and ordered fashion towards full general practitioner cover for all. Cancer patients are not on the long-term illness scheme. Leukaemia patients are on it. I have spoken about doctors who work inordinately long hours. It is not something I want to see or stand over. We know that mistakes will happen.

Senator Barrett mentioned what the troika had to say about fees. This is a difficult area. There are many apples and oranges in this scenario. The supports that are given to doctors in Belgium and France are very different from those that are given here. As the Senator knows, all of this will become historic when free general practitioner care is introduced over the next three years. I have mentioned that I am concerned about locums and the deskilling of general practitioners.

Senator Barrett also referred to the important Milliman report on VHI. Milliman has been engaged by VHI to further address its cost base. I have said in this House and the other House that I am not happy about the way the insurance companies are dealing with the cost of the provision of private care. Everybody seems to be buying into the current medical inflation rate of 9% per annum, but I am not. I do not believe it has been verified or justified.

Although I am not entitled to interfere in the day-to-day running of VHI, as its sole shareholder I will demand on behalf of its customers that there should be serious discounting of the fees charged by consultants when they carry out procedures in private hospitals that could and should be carried out in primary care facilities. I do not mind whether such procedures are carried out by consultants or general practitioners. It is utterly unnecessary for this side room fee to be attached.

Issues relating to administration and the costing of things also need to be considered. Procedures have changed and become more efficient. If I mention any particular procedure, a certain group of individuals will be very cross with me again. I do not want that to happen. I believe everybody is doing their work as best they can. We need to revisit many of the things that are happening. I will not get into the specific details. Everybody knows that archaic payments are being made for many things that often do not require the presence of a doctor. One of the clearest and easiest things that is done in our hospitals is phlebotomy, or the taking of blood from people who have haemochromatosis and need to have a pint of blood taken from them at regular intervals. VHI pays a big fee for this, even though it is done by a nurse most of the time. It should not be done in hospital. It should be done in general practice. Many such matters have to be addressed.

I have covered the question of the centralisation of means testing for medical cards. I remind the House that local staff who have an understanding of people's needs and requirements were left in place to deal with people. There was a concern and a worry that people would have to deal with a computer, which would be very disengaging.

Many speakers, including Senators Crown and Barrett, expressed concern about the health professions admission test. I am very unhappy about it because it is grossly unfair. I am prepared to say publicly that all it has done is led to the development of another industry and another course. I know of people who failed it the first time but passed it the second time after taking a special course. I want to see it changed. I will discuss that with the Minister for Education and Skills. If somebody who wants to study medicine works hard enough to get 600 points in the leaving certificate, that should be acknowledged. I accept Senator MacSharry's point that people who get 600 points are often pushed by their families into studying medicine rather than history, politics or something else. That can happen. If such a person wants to study medicine, however, he or she has bloody well earned the right to do so.

The Minister is an exception in that regard.

Absolutely. I have nothing but admiration for young people who achieve 580 points in the leaving certificate. When one thinks about it, one will appreciate that they must operate with a 3% margin of error. It is an extraordinary achievement by any standard. My view is that if people have achieved that, they are entitled to study medicine.

I have covered the question of social justice, which was mentioned by Senator Healy Eames. I reject the suggestion that we said we would pass this legislation in the third quarter of 2011. We said it would be published in that quarter. Senator Byrne also spoke about this point.

Nobody is more keen than I am to see this Bill passed expeditiously. People are wondering whether we are serious. There have been many false dawns in the past. I assure the public that we are absolutely serious. We are serious about the specialist grade as well. I do not want excellent Irish doctors to leave this country. We need them here. When this Bill has been passed and we have clarity about the other issue, I hope to be in a position to send out a call to doctors to come back to this country. Senators are familiar with the rugby song, "Ireland's Call". I will issue my own "Ireland's Call" to bring our medical professionals back.

I remind Senator Byrne that I never promised a regional hospital in the north east. I am not involved in any negotiations on it. Others may be pursuing that agenda, as is their absolute entitlement and right. I remind the Senator that his former colleague, Dermot Ahern, said not a red cent was available for the hospital. My only comment in that regard is that it is a pity he did not tell us there was not a red cent left in the Government coffers.

Senator Clune spoke about people who play golf. I have covered that issue and concur with her comments.

Senator Cullinane referred to the national service plan. I will return to the House to discuss it. I am pleased the Senator supports the Bill and the concept of primary care. He was right to say there are at least two excellent clinics in Waterford city. Groups of doctors have come together to provide a wide range of services that would not otherwise have been available in primary care. If a primary care facility is near a big hospital, it takes huge pressure off that hospital. It can be far more convenient for patients to go to a primary care centre. It is less intimidating for them to see a doctor or other member of staff in a building with which they are familiar. Even if they have to see a different doctor, they are still in their own space. It is not like going to a different location entirely.

I share Senator Cullinane's view that the health service should be predicated on need rather than on ability to pay. I am glad he shares my view. The ratio of general practitioners to the overall population is a concern. I hope this Bill will help to address that issue. The Senator mentioned Tallaght, which is an area of concern. We have had difficulties in Fettercairn in the past. This legislation will make it easier to deal with such matters. No negotiation with anyone will be required. I hope we will be successful when we offer packages to bring general practitioners to such areas. This feeds into the principle that patients should be treated at the lowest level of complexity that is safe, timely, efficient and as near to home as possible. That principle, which has been my mantra from the outset, underpins everything we are doing.

Senator Comiskey mentioned those who have to wait for a general practitioner to retire or die. It is a deplorable way to run a system. It is deplorable when it happens in the hospital system as well. It is crazy that excellent people who have studied really hard and have finished their specialist registrar training should have to wait in no-man's land until somebody retires or dies. This legislation will go some of the way towards addressing the primary care side. I hope we will be able to address the personnel deficits on the specialist side as well. I commend the Bill to the House. I thank Senators for their support.

I thank the Minister for his comprehensive response.

Question put and agreed to.
Committee Stage ordered for Wednesday, 22 February 2012.
Sitting suspended at 1.20 p.m. and resumed at 3 p.m.