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Seanad Éireann debate -
Wednesday, 22 Feb 2012

Vol. 213 No. 11

Health (Provision of General Practitioner Services) Bill 2011: Committee and Remaining Stages

I welcome the Minister for Health, Deputy Reilly.

Sections 1 to 5, inclusive, agreed to.
SECTION 6
Question proposed: "That section 6 stand part of the Bill."

The Minister might be able to clarify a concern I would like to raise about section 6. This section provides that the consent of the HSE must be acquired when someone requests to move to another location. I am concerned that the absence of a right of appeal in these circumstances means judicial review is the only avenue that is open to a person who does not receive the consent of the HSE. Perhaps provision has been made in an existing Act to deal with this issue, which has come to my attention.

Before I respond, I acknowledge the presence in the Visitors Gallery of Mr. Anders Johnsson, who is from Sweden and is representing the Interparliamentary Union. He is very welcome. I thank the Members of both Houses for the cross-party support this Bill has received. I assure Senator Burke that provision has been made in the general contract for appeals in these circumstances. It is covered in that way.

Question put and agreed to.
Sections 7 and 8 agreed to.
Title agreed to.
Bill reported without amendment.
Question proposed: "That the Bill do now pass."

I thank the Minister for always making himself available to this House. Given the busy nature of the Minister's Department, it is welcome that the senior Minister has always done so. Legislation such as this, the Criminal Justice (Female Genital Mutilation) Bill and others are less of a priority in the public mind and I thank the Minister for attending the Chamber on these matters. While we all support the Bill, I ask the Minister to monitor a number of points. I refer to the out-of-hours coverage that will be available and the viability of practices. There is an expectation that there will be a flood from the Beara Peninsula into Cork city rather than ensuring adequate services are made available. I refer to coverage in less popular locations.

Following the debate on Second Stage, I pointed out the concern about GPs in certain parts of the country where there is a casualty unit nearby and that there is a tendency to refer patients to casualty departments. I mentioned how GPs might like to play golf on a Wednesday afternoon. The Medical Independent, which I must praise for its monitoring of debate in the Seanad, has written an article specifically highlighting the negative points made in the debate about certain GPs not making themselves available to the extent that they might. I have clarified the point on its website and no offence was intended to the hard-working GPs throughout the country. The vast majority make themselves available, however true my point is about some who do not. We should monitor the situation.

I thank the Minister for dealing with this, which is an important development. I always wondered why this issue was never challenged in the courts over the past ten or 15 years. This is welcome and it opens up an opportunity for young, trained people to begin a career where they can make a contribution. It is important to give recognition to the contribution medical practitioners make in their local community. Sometimes we tend to ignore their contribution, whether helping out the local rugby club or a GAA club or giving leadership in their communities. They have been very good at doing this and we should give recognition to their efforts.

I raised a number of concerns with the Minister about people in the training process and the perception of a small minority of them that GPs work from 9 a.m. to 5 p.m. Monday to Friday and that coverage at weekends is someone else's problem. The intention and ambition of the vast bulk of people is to serve and work for their patients. A service should be available seven days a week and my colleague, Senator MacSharry, referred to coverage out of hours.

It is also necessary to ensure there is not a watering down of the primary care system, which is important. Too many people attend accident and emergency units when many issues could be dealt with at a local level. GPs have the competence to deal with many of the issues that end up in accident and emergency units. We need to give that assistance to the hospital service to ensure we are not clogging up an already overburdened facility. The number of young people who have contacted us looking for the Bill to be passed at an early date is an indication of the enthusiasm of those who want to provide a service. They have the qualifications and experience and this Bill allows them to provide the service. I thank the Minister for bringing this forward and dealing with it in an timely fashion.

Like Senator MacSharry, I welcome the Minister to the House. He has always been amenable to the House and has been in the Chamber more often than I have. I welcome the Bill and the fact that it opens up competition, which will hopefully reduce prices. GPs charge for writing letters to help someone to get a medical card when that person is probably living below poverty guidelines. Charging €50 to write a letter to help achieve this should be outlawed. A similar case involves doctors' certificates to get disability benefit.

Regarding the out-of-hours service, with more GPs coming on stream there may be an opportunity to consider services such as WestDoc because people have not bought into it and it does not work. Some of the newer, younger GPs may be willing to be on call at weekends and perhaps it will revert to the better service that it was historically.

I welcome the Minister. We said everything on this matter on the last day and the warmth of the support for the Minister in this measure is reflected by everyone. As Senator Burke said, the competition aspect of what we did previously must have been open to challenge. This measure will allow young, enthusiastic new doctors to practise and it may be just what the health service needs. To achieve universal support for the measures should embolden the Minister on his reform agenda. We look forward to hearing more about that and supporting him. If we get the new enthusiastic GP service, it affords the opportunity to move people to GPs from outpatient departments, which costs several multiples of a GP visit even though they are financed differently. Over 90% of outpatients are not admitted to hospital and I wonder if they could have gone to a GP. The Minister referred to group practice GPs, where specialties can be split between the practitioners.

Professor Drumm's book suggests pressure to equip 3,000 beds should be resisted until we get reforms. Do we really need them and is there too much hospitalisation, which costs thousands of euro every night? We know this from the hotel costs from health insurance bills. There is a real chance to reconfigure the health service, starting today, with less hospitalisation, fewer outpatients and more being done in GP surgeries. Senator MacSharry mentioned the data on de-skilling GPs, to which the Minister referred. If GPs operate too close to a major hospital, they may become de-skilled by referring many people to that hospital. Perhaps this should be considered.

I commend the Minister for the booklet Health in Ireland: Key Trends 2011, which he circulated among us. It contains facts that get lost in the current debate. While there are now cutbacks because of the financial difficulties, the number of medical and dental staff has increased by 20.2% in the past decade. There are 44% more consultants in the system and 48% more GP agreements. Page 57 of the booklet shows that, with expenditure of 11.4% of gross national income, Ireland does not underspend on the health service. Our expenditure in this regard is nearly two percentage points greater than that of the United Kingdom. The idea that the health service has been starved by evil people in the Departments of Finance or Health is incorrect. We must circulate the facts. The number of staff has been doubled since the 1980s, from 55,000 to 110,000, and we have invested resources. The economic recession affords the Minister the opportunity to carry out reforms that should probably have been carried out already. We have certainly fired a vast amount of money at the health service, and reforms such as the one in question are most welcome.

I am concerned about hospital stays and the Milliman index result that Ireland's average stay is over ten days. Best international practice would require a reduction to 3.7 days. As the Minister stated on the last occasion, there is intervention with the VHI to address the problem. Keeping people in hospital for too long, at a cost of €1,000 per night, is not only blocking beds but also costing the economy vast sums.

I join all the other Senators in stating reforms such as this one contribute to making the professions more competitive and effective as the country attempts to trade itself out of its economic difficulties. The Minister's colleague introduced legislation of a similar kind to open up the veterinary field yesterday. He received the same ready reception in supporting the House. I thank the Minister for Health. The kinds of reforms on which he is working are very important because we have spent considerable money in this area, although the public believes we have not. Sometimes it is necessary to put the facts before the public because the producers are pretty effective at lobbying. Sometimes what they say is not supported by the facts, including the fact that a substantial number of extra staff were recruited over the past decade. The data are in Health in Ireland: Key Trends 2011. Those recruited have not all been bureaucrats as many others have been recruited also, even though there may be too many bureaucrats. The system needs to be streamlined.

I would like to have competitive health insurance extracting costs from the hospital system. As the model is refocused, perhaps hospitals should be allowed to compete against other hospitals, rather than operate through the large health boards we built in the past. This might improve the overall efficiency of the system. This measure is a very good start and I support the Minister.

I am very pleased to respond and reiterate my gratitude to all the parties in both Houses for their support for this Bill. I made it very clear that although this is a requirement of the troika, it is also a measure to which I was utterly committed when in opposition. It is not right that properly qualified GPs are not allowed to treat public patients. I am delighted to bring that day to an end.

Let me comment on some of the matters raised. I am concerned about the out-of-hours service. Generally, it is a very important aspect of GPs' work. If GPs were to abandon it, they would diminish themselves considerably. Many GPs are aware of this. I say this with the caveat that it is not safe to have doctors working night and day. We can address that issue.

I share Senator MacSharry's concern that the Bill could cause a movement towards urban areas, thereby stripping rural areas of service. I have been very careful in the Bill to ensure that one cannot relocate without permission from the HSE. This will avoid the problem. From a policy perspective, we are entitled to support GPs, with additional measures, through grants for nursing, etc., in areas where we want them, be they urban areas such as Tallaght, or certain sections of Fettercairn which have not had a service for quite some time, or rural areas. We do not want the legislation to lead to the establishment of five new GP practices on Grafton Street. So be it if this happens but we will not support them.

I raised the tendency to refer patients to emergency departments in the past. I am concerned about the de-skilling that takes place when a large hospital is built in a general practitioner's area. Equally, I am concerned that circumstances could arise in which locums, in particular, could be inclined to refer patients to hospital for suturing and other work that they should be well qualified to do themselves.

GPs are hard working. They see in excess of 100,000 patients every day whereas the emergency departments see approximately 3,500. They comprise a crucial part of the health service, as it stands, and an integral part of the reform of the health service as we put more work in their direction. GPs will not have to work harder but will have to work in a different, smarter way. They will have to make more use of their practice nurses, primary care teams, physiotherapists, occupational therapists, psychologists, counsellors and others.

I acknowledge the presence in the Visitors Gallery of the China Business News delegates and Deputy Flanagan, who is accompanying them.

The relationships between GPs and their patients last for decades, and this represents a great strength. GPs know their patients so well and have an understanding of them, and patients understand their GPs also because they choose the GP they like. There is not a great difference in ability among GPs but a difference in personality. Some people find different personalities easier to get on with than others. If one suffers from depression or another mental illness, there is nothing worse than having to outline one's whole history again to a stranger. It is very comforting to return to the person who knows one's history, physical and mental. This is a real strength of general practice that avoids much unnecessary testing.

The visit over the weekend of Vice President Xi Jinping of China has strengthened our relationship with China. This will be a very beneficial relationship. I very much look forward to our Governments improving the living conditions, health services and economic opportunities of both our peoples.

Senator Burke was concerned about out-of-hours arrangements also. I have covered this but would like to elaborate on it. I am concerned about the sort of work that is being done and the sort of work being referred to hospitals. We need tighter protocols in respect of this and to audit constantly so there will be no slippage.

A HSE survey indicates 90% of the population has access to out-of-hours GP services in 14 centres nationally. Over 2,000 GPs provide services in the co-operatives. They dealt with 931,305 calls in 2009 and 924,000 in 2010. There were 859,778 contacts with GP out-of-hours services up to the end of November 2011. The pertinent figure in this regard is 64,000, which represents an increase of 8% on the figure for the same period last year. People are using the service and it is valuable, but that is not to say it cannot be improved. The breakdown of contracts with the GP out-of-hours service is: 60% GP treatment centres, 29% triage, 10% home visits, and 1% other. Attendance at a treatment centre would usually follow the initial telephone triage. These are not walk-in centres but one can pick up the phone if one is concerned and talk to a nurse or doctor who will offer advice or indicate that a person should come in to see the doctor, or that a person might even need a house call. Funding of €89 million was provided for this service, which represents value for money. If that service was not there our emergency services simply could not cope.

The HSE has carried out a national review which was published in 2010. There is a working group comprising the HSE, the Irish Medical Organisation and the Irish Association of General Practitioners which will continue to implement that review's recommendations. We should have another audit of what is happening out of hours, particularly between midnight and 8 a.m. as regards what is, or is not, being referred.

Senator John Kelly mentioned charging for letters and I can certainly examine that matter in terms of a pro forma system. From my own experience, however, I know that people can be sent by welfare officers, councillors and TDs to visit their GPs for letters. They might be sent back to get a second letter because “two are better than one”. This is time consuming, however. Solicitors charge hefty fees for letters so let us be reasonable about this. If the system did not encourage people to seek GPs’ letters for various issues perhaps that charge situation could be clarified. The social welfare system pays for social welfare certificates, in a separate contact to GPs, so the issue should not really arise.

Younger GPs who have now come into the system will be willing to work. Let us call it like it is. I know from my own time — I think Senators will acknowledge this — that when one is in the nest-building phase of one's life, one is prepared to work harder and longer to get money together for a mortgage and raise a family. As one gets older and less able to work those long hours, it is only right and proper that one should not have to do so. I am not saying that younger people should have to do it either, but the opportunity is there for them. Given their energy, they are often prepared to do it. This is where having a good system of new primary care centres comes into play. As I said before, GPs should invest in them where possible. Many people will want to keep their centres open as long as possible, from 8 a.m. to 10 p.m., to get a return on the investment they have made in the building. If that happens, it will take pressure off a lot of other services.

I much prefer the carrot to the stick, so we are working on a fund to allow for the roll-out of primary care centres. We have reckoned that around 200 might be necessary but we are refining that work to see what size these centres should be. We also want to see a roll-out of primary care teams. These would be real teams, rather than teams in name only where somebody receives a letter asking if they are interested and, having accepted that they are interested, they are suddenly part of a team and this is expected to constitute a functioning entity. It certainly does not. I said that we would be transparent around these matters and we will be. We are therefore determined to roll out the centres and teams. I am working hard, as is the Minister of State, Deputy Shortall, to achieve this.

Senator Barrett raised the issue of expenditure. We do spend as much now, and sometimes a bit more, than others. For a long time, however, we underspent and must now catch up. Even when we were spending we misspent, unfortunately, and did not get what we should have received for our money. We now have a great opportunity to address this matter and tackle it. We are 100% committed to doing so.

I agree that VHI must address its cost base, in terms of its own administration as well as what it pays hospitals, consultants and GPs for services rendered.

I am pleased with the special delivery unit. Under the stewardship of Dr. Martin Connor, it has achieved remarkable things when one considers that for 14 years we threw money at the system and all people could do at the end of the day was throw their hands up in exasperation as the trolley count got bigger. I want to remind the House and the public that in January 2011 we saw 560 people on trolleys, and I said we would never see that again. The special delivery unit has been hugely influential in achieving that. Yesterday, we had serious pressure on the system due to flu and other reasons. At 4.30 p.m. or 5 p.m. yesterday, it looked like we might have up to 500 people on trolleys today if we did not take action. In the past, we would not have had the information because they did not count trolleys at 4 p.m. like we do, and the system was unable to respond. I am happy to say, however, that across the system last night it did respond so that this morning there were fewer than 300 people on trolleys in our hospitals. I think that is worth noting. I want to record my gratitude to those who work in the special delivery unit, clinical programmes and on the front line across the system who made this possible, as well as the management who co-operated and supported those actions last night. It is always a frightening experience to be admitted to hospital for care, but they have made it less arduous for those availing of our health services.

While he is on that point, does the Minister have any thoughts about the number of children on trolleys?

Yes. We are in talks with the gentleman who has raised that concern. I did not hear his interview myself but I believe it was reasonable. We will look at that matter also. The special delivery unit has been engaged mainly with the adult service but Mr. Gerry Dwyer, who is in charge of the three paediatric hospitals, is engaging with Dr. Eoin O'Sullivan. I look forward to hearing the outcome of those discussions and what action we might have to take. I have always said that we would commit to looking after the most vulnerable. It is a measure of any civilised society and a compassionate government that the most vulnerable will be cared for, even when we are under such financial pressure. That is why we are seeking to build the national paediatric hospital to improve outcomes for our children. That is also why we will build a central mental hospital to look after those with serious mental health issues. We are focused on ensuring that we have the capital programme in place to extend radiation oncology across the country for those who have the misfortune to develop cancer, which we know will become more prevalent as our population ages.

I thank the Cathaoirleach and other Senators for their positive support for the Bill, as well as their many constructive comments and suggestions. Today we have done a good job for future generations by ensuring that we will have the maximum number of GPs available, and that there will be no obstruction for those who wish to serve their communities as GPs in future.

Question put and agreed to.
Sitting suspended at 12.40 p.m. and resumed at 2.30 p.m.
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