General Practice in Disadvantaged Areas: Discussion

I request members, delegates and observers in the Visitors Gallery to ensure their mobile phones are switched off completely because otherwise they can cause many problems for the recording staff. They can also cause interference with recordings.

I welcome everyone to this our third day of public hearings on health care reform. Apologies have been received from Deputy Pat Buckley.

In considering its work programme the committee identified all primary care services as a key work stream. It referenced the need to reorient the health service to put the focus on primary and community care services. The meeting will focus on two aspects of the debate on the role of primary care services in any future health care model. In our first session we will consider some of the issues faced by general practitioners, GPs, working in areas experiencing significant disadvantage. We will hear evidence from Dr. Edel McGinnity, Professor Susan Smith, Dr. John Delap and Dr. David Gibney who are representing the group Deep End Ireland, a group of GPs working in disadvantaged areas throughout the country. In our second session we will hear evidence from Dr. Ronan Fawsitt and Professor Garry Courtney who will brief the committee on the Carlow-Kilkenny model of care which has been developed over time and from which we believe we can learn a lot. Both sessions will I hope allow the committee to explore the barriers to developing primary care services which are vital in managing issues such as chronic disease in the community.

I welcome our visitors. We are delighted to have them and I thank them for coming to represent Deep End Ireland.

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

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I advise members that the opening statement has been circulated. I invite our visitors to commence their presentation.

Professor Susan Smith

I thank the Chairman and members of the committee. We very much appreciate the opportunity to make our presentation. Before making our opening statement, we will introduce ourselves. I am a general practitioner in Inchicore, Dublin. I am also Professor of Primary Care Medicine in the Department of General Practice at the RCSI.

Dr. David Gibney

I am a GP in Ballymun.

Dr. John Delap

I am a GP in Coolock, north Dublin.

Dr. Edel McGinnity

I am a GP in Blanchardstown, Dublin.

Professor Susan Smith

We are a group of GPs working in disadvantaged areas, but we represent a larger group across the country. We have called our group Deep End Ireland which has been modelled on a similar project in Scotland that has been running for a number of years and is called General Practice at the Deep End. We will start by presenting some of the evidence which highlights the poorer health outcomes experienced by patients living in deprived or disadvantaged areas. We will then present a description of what is called the inverse care law and a related case history example. We will also offer some potential policy solutions, following which we will be happy to address questions.

Patients living in the most deprived areas have significantly poorer health outcomes than those living in the most affluent areas. They have lower life expectancy and higher mortality rates at all ages. When they get cancer, they tend to present later and are twice as likely to die from it. Not only are they more likely to die prematurely, they also have higher rates of chronic conditions and are more than twice as likely to have heart disease and be at high risk of having a stroke. They are also more likely to have multiple chronic conditions referred to as multimorbidity which occurs ten to 15 years earlier among the most deprived members of the population. GPs working in the most deprived areas tend to have approximately 40% more patients with multimorbidity than GPs working in more affluent areas. This is further complicated by the fact that patients living in deprived areas are more than twice as likely to have a combination of physical and mental health problems, with rates of 113 per 1,000 patients compared to 52 per 1,000 patients in the most affluent areas. These patients often struggle to manage acute and chronic conditions while facing other social and financial pressures.

I draw the committee's attention to a graph we have circulated which highlights the evidence which underpins the difference in health outcomes. Along the bottom line, one can see No. 1 represents the most affluent populations, down to No. 10 which represents the most deprived. The red line indicates the level of physical and mental co-morbidity, while the blue line indicates the level of standardised mortality. The black line is fairly flat right across the different groupings. It represents the flat distribution of funding, despite the clearly different needs among the most deprived populations. Complex multimorbidity is much more common in practices in deprived areas and reflected in higher consultation rates, but it does have ramifications throughout the health service. The 10% of patients with four or more chronic conditions account for 34% of unplanned emergency admissions and 47% of preventable unplanned admissions.

While we acknowledge the impact of wider social inequality on poorer health outcomes, we are going to focus on the challenge and opportunity to provide GP care for the most deprived patients. This GP care is delivered within the context of what has been referred to as the inverse care law. Dr. McGinnity will explain this further and present an anonymised case history that illustrates the challenges and lost opportunities.

Dr. Edel McGinnity

The term "inverse care law" was first coined in the United Kingdom in 1971 by a GP by the name of Julian Tudor Hart. It describes how the people who are sickest are least likely to receive an appropriate health service. It is a common expression, but what does it mean in practice? If members look at the coloured diagram I circulated, it is about what happens when one distributes services according to numbers, not according to need.

The first drawing represents an average or affluent area versus a disadvantaged area with 1,000 people in it. There is one health service which could be provided by a GP, a public health nurse, an occupational therapist, a hospital and an ultra-sound machine. Within the 1,000 people a certain number will be chronically ill or are going to die. With the same distribution of resources in a disadvantaged area, as Professor Smith outlined, the mortality rate is much higher, as is multimorbidity. Within the 1,000 people one has twice as many sick people and people who are going to die, but one still has only one GP, one public health nurse, one hospital and one ultra-sound machine. Therefore, one is effectively offering these patients half the service by distributing resources flatly according to numbers across the system.

The diagram illustrates an extreme version of this and what happens in certain areas of disadvantage where numbers are not even equally distributed. The national average for GPs to patients is one to 1,600, but in north-west Dublin where I practise it is one GP to 3,600 patients. Within a given population, a GP has twice as many patients, twice as many of whom are sick or who are going to die. That is a really extreme version.

There are many reasons for it and we are going to outline the nature of practice in these areas which leads to these problems.

One of the core reasons relates to the way the general medical services, GMS, scheme is funded according to capitation. This means we get a fixed rate for a patient for the year, regardless of the number visits, regardless of whether it is one, ten or 100 visits a year or whether the visit lasts for five, ten or 50 minutes. The only variable within the GMS scheme payment structure is age. Research from the United Kingdom shows that a 50 year old living in one of the most deprived areas will consult at the same rate as a 70 year old living in one of the most affluent, and yet the fees are far lower. On the periphery of the big cities, the average population is far younger and, as a result, in certain practices the average GMS payment per year is actually far lower than the national average. In north-west Dublin, for example, it is 74% of the national average but morbidity and mortality is far higher in younger patients in these areas.

Unfortunately, the inverse care law pervades the system. It is not only prevalent in primary care - although it is obvious to those of us in primary care - it is also a feature of many other services that our patients need, especially diagnostics. There is a good deal of variation within the public system in essential tests, such as ultrasound and colonoscopy tests. We need to carry out these tests for our patients to identify cancers early and so on. There is extraordinary variation, however. A great deal of our time is spent trying to access services for patients, especially locally in our communities. This applies to all primary care services. Since they are distributed according to number, there are not nearly enough of them for the needs of the population. Critical support services for vulnerable families include child and adolescent mental health services, child psychology, occupational therapy, child protection and access to social workers. The supply of these services is much slower in the areas in question, yet the needs are so much higher. The delays compound the existing problems for patients and this adds to the burden for those of us trying to care for them. We have to contain them, hold them safe and manage considerable risk while trying to access the services that our patients have such difficulty getting. Moreover, there is no safety valve. They cannot go instead and see someone privately or get a private MRI or ultrasound scan.

I will briefly describe a typical morning in my practice. It is typical of many practices throughout the country. The patient I will talk about is a woman called Catherine who is 54 years of age with multi-morbidity. This is very common. General practice is all about multi-morbidity now but in these areas it comes far younger and it is complicated by psycho-social problems. Catherine is 54 years old. She has a background of chronic lung disease, diabetes and eczema. She is struggling with a 13 year old daughter who has behavioural problems. In the background, she is still smoking. I know her diabetes is not well controlled because I checked her blood levels on her previous visit. Her smear test has been overdue for a year. My system reminds me of this, as does my nurse. Catherine has missed a couple of appointments for the test. She is down today with a chest infection and a flare-up of her eczema. She comes in, sits down and we start dealing with it. As is typical in our practice, unfortunately, the telephone rings. Normally, we would never take calls during a consultation but this is an urgent call from a child protection social worker who needs me to drop everything because she is going to court later that day for a care order in respect of a vulnerable child. I am the only professional who has seen the mother of that child in the past week. They want a letter from me about my opinion on the capacity of the mother to care for her child. Catherine has to leave then because I have to have that conversation, write the letter, go to reception with the facsimile and then come back. Then, I call Catherine back in. She goes on to tell me that she has not been sleeping for the past month because her niece died after an illness. She then tells me her daughter has just been suspended from school, which is the thing worrying her most today. She needs a letter for clothing and she has to have it today. It is urgent because she does not have the money to get runners for her daughter. Meanwhile, the waiting room is full of many more patients like Catherine, all waiting to come in to have these things dealt with. In any event, we work our way through the chest infection and eczema. We look at the diabetes but the diabetes was very much impacted upon by the illness and death of her niece. It caused her eating to go all over the place. We agree not to change the medication and to wait to see if things would settle down. We talk about her bereavement and other bereavements that she has had as well as her lack of sleep. We talk at length about her 13 year old daughter who has been suspended from school. She missed her children and adolescent mental health services appointment because of the funeral. As a result, I have to write a letter later to get her back into that system. I have to write a letter for the school as well. We consider talking about her smoking but she is really upset today so I do not think it is a good day for it. We arrange the prescriptions, her next appointment and the letter for the clothing, which is critical for her. Then, when we have done all that, we remember that she still has not had her smear test. I put it to her that we need to do the smear test today but she says she is simply is not in the humour for it. I am not in the humour for it either because the waiting room is packed and so much has been going on.

Ironically, these patients are often called "hard to reach" by services. CervicalCheck is a brilliant cervical screening programme. The uptake is far lower in our areas even though the mortality rate relating to cervical cancer is higher there. These people are hard to reach for screening programmes and many other things but they are not hard to reach for us. They come to our practices every day of the week. However, their acute mental health, social and physical problems are so overwhelming that we do not get to look after their chronic illnesses or undertake cancer prevention or screening. These are all the things we could do and they would make such a difference to them now as well as down the track. They would prevent these patients from getting sick and presenting later on with cancers, like they do. They do not simply need more GP time, they need more administrative time and a great deal of support time. Our secretaries spend a good deal of their days telephoning and texting people about their appointments with us and the hospitals. That is, if we know when those appointments are coming up - we do not always know. We need a good deal of time to liaise with our primary care colleagues. Unlike some parts of the country, primary care teams function very well in our areas because we need them and our patients need them. We need to spend a good deal of time liaising with them. They are under-resourced and understaffed but they are absolutely fantastic professionals. Public health nurses in particular are an incredible help. They are the backbone of the health service. They do not get much notice but they are very important. I have tried to explain a typical morning and how it is that acute health and social problems act as a serious barrier to chronic disease management and cancer screening and prevention. Even when our patients have a general practitioner, they still do not have appropriate access to proper care.

Dr. John Delap

We have outlined many of the challenges facing general practitioners working in areas of socioeconomic deprivation. I wish to highlight that there are also great opportunities to improve outcomes throughout the health system. We have some suggestions based on the experience of GPs in Deep End Ireland, as well as those in countries such as Scotland. There is an overarching need to target resources where needs are greatest - we want to emphasise that point today. Within this context we want to highlight four main areas. First, there is a need for fully-functioning primary care teams in disadvantaged areas in particular, where team-working is such a key part of delivering effective care. This means ending the recruitment embargo for primary care team front-line workers in these areas and matching personnel to local needs. Second, we need strong primary care infrastructure in deprived areas to act as local hubs around which local services should develop. This is related to our third priority area, which is the provision of support to general practitioners and practices in these areas. GPs need more consultation time to address the complex needs that we have described. The flat distribution of resources, a feature of the inverse care law, means that the only way GPs can currently deal with the increased demand in deprived areas is to have shorter consultations. This results in missed opportunities for prevention, cancer screening and chronic disease management. A change could be facilitated through a deprivation weighted capitation payment in a new GP contract or through other options, such as providing salaried GPs to practices and additional practice staff or additional funding for practice nurses and administrative staff. The fourth priority area relates to the extraordinary pressure resulting from the lack of access to diagnostics and other speciality care supports. While this may be a national problem, it is substantially worse in areas where there are greater health needs and where people do not have the option of the resources of private health schemes.

I thank members very much for taking the time to listen to our views and suggestions. We are happy to clarify any issues they wish to raise and to answer any questions.

I thank Dr. Delap and the other members of the delegation for their presentation, which was very sobering. We will start with Deputy Barry. Is the Deputy ready to proceed?

Not quite. I will do so later.

Deputy O'Connell is next.

I wish to clarify a point that has been made. Would a deprivation weighted capitation payment be based on the need of the patient, so that a larger payment would be received for a patient with many complex issues, rather than the headage payment normally received for a patient through the General Medical Services, GMS?

Dr. Edel McGinnity

This is one possibility. A patient in an area of great disadvantage could carry a slightly higher capitation payment.

Is there a method to assess this? I am a community pharmacist and the same issue arises in that one could be an hour with somebody because the person needs it and not because one is chatting, and somebody else could be out the door in 30 seconds. Is there a method to assess the complexity of people's illnesses and how we could assign capital to them?

I ask the witnesses to bank and note questions and I will bring in three committee members at a time.

I thank the witnesses for their presentation. I am also a community pharmacist and I am very well aware of the huge difficulties in the GP sector. Solving and improving primary care will be key to the future of health care provision. I imagine it will be a huge part of our report. As it stands, GP care is the one area that deals with people's sickness as opposed to their ability to pay. Everyone going to a GP practice gets examined and treated regardless of whether people have a medical card or are private patients. When they go in the door they get looked after. I imagine the more facilities and services we have, the quicker this will happen.

Is the percentage of referrals to hospital greater in deprived areas than in more affluent areas? I suspect it might be, which means there is a very strong case to be made for resourcing GP practices properly, which would save on very expensive and sometimes unnecessary hospital stays. I am interested to hear the comments of the witnesses on this. To what level is the issue one related to socioeconomic background rather than a medical problem? If the witnesses had a fully serviced ideal practice set-up, would they still be a good bit ahead of the curve compared with more affluent areas? How difficult is it for the witnesses to recruit? I live in a rural area and we had a big problem several years ago recruiting for what I consider to be a very attractive GP practice. If it is that difficult in rural areas, is it much more difficult for the witnesses? How might we get over this?

I would like to hear the opinion of the witnesses on the following matter. I have received many inquiries in my constituency offices about the human papillomavirus, HPV, vaccine and problems associated with it. As the issue has been raised by the witnesses, is it something they have heard in their practices from parents?

If the Deputy does not mind, we might leave that last point to be dealt with by the Joint Committee on Health. It is somewhat outside our remit.

I was looking for a comment rather than anything else.

I thank the witnesses for their presentations. The report notes that in 2015 there were 21 GMS vacancies. Do witnesses have the figure for this year? Given that the report highlights that the benefits of the rural practice allowance remuneration wear off after approximately five years, how do they feel a deprivation allowance would best work? How can we best implement it in order that it has a long-lasting effect for GPs and that it works? With regard to GP retention in rural areas, I am interested in the suggestion that trainees are placed in rural GP practices. Are there examples of where this has worked? Would it improve the retention rate of GPs in these areas?

On the unequal access to diagnostics of patients in deprived areas, the witnesses referred to a lack of access to private services, but are other diagnostics generally not available in these areas? Will the witnesses expand on this? Is it the case that if patients cannot access public services they have to access services privately? What are the diagnostics that are not available in deprived areas?

Professor Susan Smith

I will combine the questions on the capitation payment and the practice allowance because they are interconnected. The idea of a deprivation weighted capitation payment is that it is based on the patient rather than where the practice is, so a practice with higher numbers of very deprived patients would have patients with a higher weighted capitation payment. This is how it would work. This is one of the models used in the National Health Service, NHS. However, as the committee can see from the data from Scotland, it is not enough on its own. The practices need to be resourced in other ways as well as through weighted capitation payments. To answer Deputy O'Connell's question, various deprivation indices are used which are developed using CSO data. It is based on individual patient characteristics, and the deprivation is weighted based on these characteristics. Technically it is very easy to do. It is a bit of a challenge at present because we would largely need to use primary care reimbursement service, PCRS, data which need to be explored a little more because we would need to know where the patients live as opposed to where the practices are based.

Dr. Edel McGinnity

It is important to note that deprivation is not just a feature of urban general practice. Some of the most deprived parts of the country are all along the western seaboard. One of the reasons we are concentrating on urban general practice is because the number of people involved is much higher in cities. A weighted capitation payment would have the benefit of distributing the deprivation allowance equally everywhere there is deprivation. Every practice that has patients in these areas would benefit from it. There are other possibilities. We could decide that if 60% of the GMS patients of a given practice are in an area of extreme disadvantage, the practice could be entitled to an extra practice nurse or a salaried GP. There could be different ways to approach it. The easiest way to do it generally would be with a separate payment attached to each individual patient.

A deprivation index is available on a very small area basis. Literally half a housing estate is profiled and these data are available to the CSO and various other people.

Dr. Edel McGinnity

Absolutely. There are enormous data about it.

Dr. David Gibney

A question was asked about socioeconomic background and whether putting in place structures helps. In Ballymun we were lucky enough to have a purpose-built health centre put in place where the primary care team and some secondary care services moved in. The arrangement has been very successful from the point of view of having everything in one building. Quite often, the public health nurses are our eyes and ears. They can tell us that they have been to a particular house and a certain person is not doing well and needs a visit. A lot of integration of care takes place, which does not happen without co-location. This is particularly useful in deprived areas. The problem in Ballymun is that we have now grown so big.

The whole health centre can only manage to have about 10,000 patients. The population of Ballymun is bigger so there is a need for another health centre.

Having an infrastructure and all the services in the one building in deprived areas can make a big difference to the lives of patients. Unfortunately, they still have chronic diseases but such infrastructure allows us to deal with patients better. We can deal with patients in the community as opposed to dealing with them in the hospitals.

The real problem that we all have is access to diagnostics and secondary care. In terms of the diagnostics that I would have difficulty accessing, a chest X-ray is fine but it would take six months to access an ultrasound. A six month wait is the best that one will get. We do not have access to MRI and CT scans. If somebody comes to me suffering a persistent headache, and no red flags to indicate he or she must go to hospital, a standard investigation would be either a CT scan or an MRI scan but we would have to refer him or her to a neurology department. The waiting time for an appointment in a neurology unit ranges between 18 months and two years. If the person manages to remember to avail of an appointment two years down the line, which I certainly would not, he or she then must wait another year to get an MRI scan. It means people fall out of the system. The problem for him or her is uncertainty. One may have a headache that one thinks is serious. Unfortunately, one must await an MRI scan but see a neurologist so it is very hard to get rid of and treat that headache. In other countries there is protocol-driven access to those diagnostics that are useful. Such a system works. We are not saying there should be open access to everything but protocol-driven access would be helpful.

In terms of outpatients, every day we receive letters in the post that are either validation letters or state someone has missed his or her appointment. The system does not work for our patients. There is a high level of functioning illiteracy and it is hard to get our patients to make hospital appointments. Also, their phone numbers change. One of the questions we ask every time a person comes to our practice is "What is your phone number?" because patients change their phone numbers all the time so one cannot use a phone number to contact hospitals without checking. Therefore, more time is required to co-ordinate getting people into hospitals. There is a major barrier to getting people into secondary care so we are left keeping people with more chronic diseases in the community. That is a real difficulty, but having a building and the primary care team co-located makes a huge difference.

Dr. Edel McGinnity

I will respond to the question from Deputy Brassil on the balance between social and medical backgrounds. I described a case in which diabetes is a serious health problem. The management and control of my patient's diabetes is caught up in her social situation so it is impossible to separate the two. There are many things one can do. One of the biggest contributors to ill health is smoking. A women's no smoking group has been set up in the area that I work in by the Irish Cancer Society, the HSE, the primary care team and ourselves, and we are closely linked.

One of the key things about general practice, and why we would like to see it placed at the centre of care in these areas, is that patients trust their GPs. They will trust us when we refer them to a service or counsellor. Patients are often slow to access services off their own bat but they will avail of services if we recommend them and tell them that another patient has had a successful outcome. A women's no smoking group is a primary care initiative that has worked well. It provides good social support to the women over six weeks. Many of the participants have stopped smoking and they have all benefited. Their health will hugely improve. A couple of these groups have been started and quite a few of my patients have stopped smoking plus their health has improved enormously. Social and medical backgrounds are intimately connected and general practice is at its fulcrum because we deal with everything, and are accessible every day.

Deputy Brassil also asked for the percentage of patients from disadvantaged areas who are referred for hospital care.

Professor Susan Smith

I do not think we would be able to give the Deputy that statistic. There is likely to be some variation but we definitely know that the rates would be higher because there is a higher amount of chronic diseases. Referrals are based on the underlying chronic conditions.

During the summer I attended a presentation by GPs in Cork who said the percentage referral averages between 6% and 7%. I am sure that we can come up with an average cost per referral. If we had that, we could calculate how much money would be saved if referrals were reduced. Savings could be redirected towards general practitioners. Statistics would help us to make a strong financial case for investment in services that would reduce the number of hospital referrals. A 1% reduction in referrals amounts to 200,000 people.

Professor Susan Smith

There is a major opportunity in terms of emergency unplanned admissions because they are even more expensive than our patient referrals.

In June, an interesting study was published by the Deep End group in Scotland on a Care Plus intervention that was delivered at a systems level. The group gave more consultation time to GPs to manage complex patients in deprived areas and carried out an economic analysis. They found that the intervention was cost effective at a quality adjusted life year rate of £12,000, which is well below any of the funding thresholds that were used for any of our health service interventions. That relates to reduced hospital utilisation as well as improved well-being and improved health conditions for the individuals involved. There is evidence that if one targets one's resources effectively at these complex patients living in disadvantaged areas, one will save money for the whole system.

It is time to take questions from another group of members and I call Deputy Louise O'Reilly.

Is there scope for improvement if new technology and near patient testing were introduced? There has been decades of under investment and there are more reasons that people cannot access hospitals. Is there a role in GP practices in disadvantaged areas, specifically to offset some of the problems created by delays in accessing hospitals, as outlined by Dr. Gibney?

In terms of a higher capitation payment with the deprivation link, would that be reduced if the number of services increased? If one had more services, one would not necessarily need a higher amount of money. What would happen if services were linked to the deprivation rate, in terms of the ratios, rather than the money? If the GP practice had a choice in this matter which would be most beneficial?

My next question is in terms of the education project, specifically the community-based project to assist women to give up smoking, which is a very worthwhile cause. Can the GPs identify other projects?

I apologise for being a bit late arriving but from what I have heard, the amount of time is paramount. Earlier Dr. McGinnity said that she had to leave one patient to deal with another patient. Is there scope for taking some of those issues out of the surgery and into the community, and assisting in the management of long-term issues like smoking? If there is scope, what form would it take?

I thank the delegation for their attendance. Of all of the committees that I have sat on, this one has provided more solutions than I have ever heard in terms of any issue that we have tried to tackle. It is great to hear so many solutions. We must now work on how to implement the solutions and get them up and running. It is great to hear positive, concrete, direct, straightforward and logical solutions from GPs who work on the front line of health care.

My first question is on GP provision for children under six years of age. How have GPs working in disadvantaged areas reacted to the initiative? Has there been a significant increase in throughput? The initiative has led to additional pressures but I would like to hear how the scheme has worked in disadvantaged areas. Have GPs working in disadvantaged areas had a different experience than other surgeries in terms of the initiative?

Can the delegation comment on the role of practice nurses? Earlier we heard an interesting take on a consultation with a patient called Catherine.

It strikes me that much of that could have been done by a practice nurse, as I am sure the witnesses will agree. How is the role of nurses in surgeries working out and how would Deep End Ireland like to see that enhanced and improved? I suspect it is a big part of the solution.

The issue of the shortage of GPs was addressed but I am not sure it was fully answered, although it may have been. The weighting of deprivation payments is an interesting concept and very worthy. I suspect that, in practice, it would be more possible in this area than in others. We tried this in the education area through the allocation of additional resources for children with special learning needs and there was an attempt to have a generic allocation model for all schools targeted at individual students from disadvantaged areas within each school. However, the schools had a big issue with collecting such data from parents and asking for information on who has what, and so on. Of course, in this case, the PCRS would have a lot of that data through the application process for the medical card, which applies to many people, so it makes it more possible.

We talked about referrals to hospitals. With regard to referrals to emergency departments in particular, is there a significant difference in areas of disadvantage? I want to hone in on unnecessary referrals to accident and emergency in that, as I understand it, anyone can call an ambulance, even with a pain in a toe, and the ambulance has to take the patient to the hospital's emergency unit, where they enter the triage system. There are hours of delay and the ambulance is held up at the hospital door and is not released, and all of that. What are the witnesses' comments on the issue of referrals to emergency departments?

With regard to diagnostics and X-rays, I had experience of the Spanish model of primary care when one of my children had an accident there on a bank holiday Saturday night. We could go to the local primary care centre where head injuries were ruled out, the wound was stitched and we were back in the apartment 15 minutes later. It that had happened at home in west Cork on a bank holiday Saturday night, I would have been in Cork University Hospital for hours, which is crazy. Will it ever be possible for X-rays to be introduced at primary care level and what is the critical mass of patients required, or will this always be kept in the hospital setting? I would be interested to know.

I thank each and every one of the delegates for coming before us this morning. It was a very interesting presentation. I was reminded of the fact that, many years ago, when I was a secondary school student studying history, I was enormously impressed with the story of Dr. Noel Browne. I have always felt, since that time, that doctors speaking out against the problems which bear down on low income, working class communities provide a powerful voice. I would also say it is a pity there are not more doctors, in particular GPs, who speak out about the issues and problems that confront communities. It was a really interesting presentation.

My understanding of the analysis provided by the witnesses is that there is a double discrimination operating in low income, working class communities, in that there is social disadvantage - low pay, low incomes, poverty and so on - and then a disadvantage and a discrimination in the way the health service itself is set up, and that the witnesses want to concentrate on the second part of that today. In that regard, there is one issue I would like to clarify and there are two questions I would like to raise.

The point I want to clarify concerns the principle of what the witnesses described as the inverse care law. As I understand it, they are saying that if GP resources are distributed according to size of population, then, because more people are likely to present to the GP surgery in a low income, working class community, there is less of a service available for them. Am I correct that the witnesses feel that, on top of that, it is often the case that GP surgeries in those communities have to serve a greater population? Am I also correct that, if there is a situation where people are twice as likely to present and the population area is twice that of a more affluent area, the level of health care being provided by the GP, and that can only be provided by the GP in that community, is a quarter of what would be the case in the more affluent community? If that is the case, it is a stunning statistic, but I am looking for clarification that I have understood the basic idea.

How much time does someone presenting to a GP in the communities represented by the witnesses have with the GP? Obviously, there is a huge difference between having a 20 to 25 minute consultation and a ten or 12 minute consultation. I read a story recently about how GP consultations in the UK are now often less than ten minutes. What is the position in the experience of the witnesses and can they generalise as to the experience overall? Do we have that experience of people coming to a GP and having ten minutes or less? How bad is the problem?

The Deep End Ireland submission states:

There is a need for fully functioning primary care teams in disadvantaged areas... This means ending the recruitment embargo for primary care team front line workers in these areas and also matching personnel to local needs.

Will the witnesses give a little more of a flavour of what the recruitment embargo means in practical terms on a week-to-week basis?

There were a lot of big questions there.

Dr. Edel McGinnity

On the final question, I do not think there is an official recruitment embargo but there is a de facto embargo because HSE local areas have to manage their budgets. Effectively, when somebody leaves for any reason, they are not replaced. For example, with regard to child psychology in my part of Dublin, one of the child psychologists left and was not replaced, and there is now a 14-month wait for a child psychology appointment there whereas it is about three months in Lucan. That is what happens across all of those services.

The document refers to matching the numbers. For example, the public health nurses, who are very much to the forefront of care, are distributed in the same proportion in all areas whereas there needs to be at least 1.5 public health nurses in certain areas compared to one nurse in another area.

Dr. John Delap

To address the issue of neuro patient testing and radiology, the experience and practice of neuro patient testing has not been very good. The technology is expensive. If it is a test that is only used infrequently, it is not worth the investment so, by and large, investigations that are provided by a unit that is set up for the investigation, as opposed to the practice, make more sense.

I have two examples of radiology in general practice. I trained in the UK a very long time ago. The practice where I trained was established by the Nuffield Trust and a radiology unit was put in place in the mid-1970s. By the time I was there in the early 1980s, the radiology unit had been closed because it was not effective. Likewise, the Ballymun health centre had a radiology unit fitted to it when it was built, and that room is still unused. Bringing radiology out to GP practices is something that has not been successful so far. However, there have been initiatives to give GPs additional access to imaging in ultrasound and radiology in the past, which has certainly benefited patients.

Dr. Delap says it is not used. Is that because it is not equipped or because there is no need for it?

Dr. David Gibney

The equipment was put in when it was built and it was envisaged it would operate as a minor injury unit, a bit like the example that was raised, where people hurt themselves at weekends. However, it was never developed like that. The centre developed as the economy was falling and that aspect was not developed. Eventually, it was moved to Blanchardstown.

There was a half-time post for a radiographer to come out to Ballymun who was linked into the Mater Hospital but that then fell by the wayside and they ended up being subsumed into the Mater Hospital. That is my memory of it. The machine that was moved out was never used.

There are a couple of issues there. Obviously, it is about properly resourcing a diagnostic facility and having the full range of staff. The critical mass issue also arises. We need to revisit diagnostic services within primary care and the community and where it makes sense.

Do the witnesses feel as practitioners that it is the way forward or do they think the system is too complex and tied up in the acute system and that it is not going to work?

Dr. David Gibney

It is hard to see it in terms of the short term because it requires unpicking so much. As the Deputy notes, it does work in other areas where primary care units are set up and there are minor injury units associated with them. There would need to be a mass of people to make it a proper minor injuries unit. That is separate from what we do in primary care.

Professor Susan Smith

It might be more relevant to out-of-hours working. Dr. Gibney is describing an experience in an emergency setting where that out-of-hours centre is possibly covering 20 or 30 practices so one then gets into economies of scale. It may be more appropriate to use that rather than using an accident and emergency department. I certainly think it is worth-----

Deputy Barry must leave to attend another committee meeting. Could the witnesses address the two questions he asked about double disadvantage and consultation time?

Dr. Edel McGinnity

We tend to have very large lists and because of the underpayments, a doctor needs more patients to be viable, which means they will have less time with them. There are many patients in north-west Dublin who cannot get a GP at all. They may have a GP in another part of the city where they have lived previously but their care is terrible because they cannot get to that GP and they only go when they are really stuck. There are more patients per GP list - not twice as many in the sense that a doctor just could not function with that many but patients do not have the GPs and must go all over the place to find their GP.

Professor Susan Smith

In respect of the question about consultation length, the average consultation in Ireland is about 12 minutes. It is two minutes longer than in the NHS. It is like that earlier graph I showed the committee about flat funding. The only way someone can deal with more health needs in sicker people is to reduce consultation length. If someone has to see more people, they must see them in less time. That is a real problem.

So 12 minutes is the average length of time but there would there be cases where it was ten minutes or less?

Professor Susan Smith

It could be five minutes.

Five minutes?

Professor Susan Smith

It can happen if someone is running late at the end of a morning and they have a full waiting room. This is all based on the need to see people. Some people will be seen for 15 or 20 minutes. The case presented by Dr. McGinnity could not have taken ten minutes.

Dr. Edel McGinnity

No.

Professor Susan Smith

So-----

Dr. David Gibney

It is a mishmash in general practice. There are ten-minute appointments with an hour's break in the middle so, realistically, they are 15-minute appointments. We still run late but we try to keep to that. Some people would come in just to get their blood results or a prescription for something and they have made an appointment for that. There are other people who could be there for 30 or 40 minutes and then the doctor is behind. We do try to give people the time they need as they need it. The thing about general practice is that we are in the community. We can say to them "you need to come back to me again because I haven't had enough time to deal with that. We'll deal with this today and make another appointment to do that." One does not have to do it all in the one session.

Dr. Edel McGinnity

Dr. Gibney mentioned earlier that the hospitals are structured to suit themselves with all their validation letters. Many services are like that. Our patients get told many times they are not eligible for this service or they do not fit into that category and we get that on behalf of our patients, most notably with child and adolescent mental health services, CAMHS. It can be very difficult to get a patient seen there even though one might have a lot of experience with the problems. Accessibility is key for people. There are not that many services that people can go to every day. It is a very precious and good thing but it means that we have no control over the average morning. One could see ten or 20 patients. It could be just crazy and then one gets those telephone calls and it is all over the place.

I thank the witnesses. That was very helpful. I must now see a Minister about a bus strike.

Dr. David Gibney

Somebody asked about practice nursing. We have been lucky in that we are in a really good building with four different practices. We pool resources, etc. I work with three GPs and our practice nurses look after the diabetic clinic. A link has been developed with Beaumont Hospital and the Mater Hospital and they come out once a month and see difficult patients for us. We have put in place a programme that works quite well. It is still very difficult but it works reasonably well. Our other practice nurse runs chronic obstructive pulmonary disease, COPD, clinics and asthma checks. She does all the smear tests and has become a prescribing nurse practitioner. She has just finished the course. There is a huge room and practice nurses have a huge role to play in the development of general practice in these areas. At the same time, it would be foolish to underestimate the need for oversight as well. A doctor must oversee it because problems arise. We work it together and it works quite well. There is definitely a role and it makes a huge difference when one does that.

I think the Deputy asked about community-based projects. One of the things having a proper primary care team has allowed us to do is to make links with the community. This is really important in deprived areas because communities are incredibly resourceful. They have developed a lot of resources in respect of the needs that have arisen in their communities. Our physiotherapist has a "back on track" programme whereby a patient with postural back ache can go to the physiotherapist in our centre. Our physiotherapist is particularly enthusiastic and has organised that the patient can go over to the local leisure centre and do a free six-week course with a trainer and the physiotherapist. The idea behind it is to demystify going to the gym and to encourage people to get involved. If they take part in that programme, there is a reduced membership fee for the first year. It is about using the resources we have in our area. We would always have been on the board of the youth action project and the drugs task force. They have funded an addiction counsellor who works in the practices one day a week so there is a linkage. That linkage between what is going on in the community and what we are doing in general practice has been really useful. Those things are really important in deprived areas because there is a wealth of experience in the community about what is going on and one can tap into it. However, it takes time.

We are talking about recruitment. We would all be GP trainers and the vast majority of people who train in our practices really like working in the areas they are in. How does someone set up with a list size that is not viable when they do not have premises? It is not possible do this in areas like ours. One needs infrastructure to attract people. It is not because people are not attracted to working in those areas. It is because it is not financially possible to do so.

Would salaries go some way towards-----

Dr. David Gibney

Yes, definitely.

Dr. Edel McGinnity

In response to an earlier question, the patient had missed a couple of appointments. One of the key complicating factors for our patients are their psycho-social problems. What often happens is that they miss their appointments and in Catherine's case, it was because she was going to the funeral and was then at the school trying to sort out her daughter's problems so she missed booked appointments. One then has to be flexible enough to catch them when they turn up with what is important to them, which in her case, was her clothing letter and her chest infection. I needed to create the time to capitalise on that to carry out the smear test but I did not. We have two fantastic practice nurses who carry out huge amounts of that chronic disease management. It is difficult for many of our patients who have really complicated lives. One needs to be flexible with them.

We have some slight insight into it because we spend a lot of time running clinics and meeting people, realising that one cap does not fit all and that five or ten minutes is not enough when something is complicated. I absolutely accept that aspect of it.

Dr. Edel McGinnity

Deputy Jim Daly asked about children under the age of six. That has not had such a big impact in our area because most of our under sixes already had medical cards. The ones who have them definitely take up time. Parents need to be reassured and so on. In terms of where that money could have gone, there is a really critical family therapy service that has lost two staff and is now so restricted that it only takes referrals from Tusla. We could have used that money for the under sixes who are having a lot of problems.

I do not like using the word "abused" but the common perception is that it could have been abused, that people would come in and out of surgeries for no good reason just because they can do so. Is that an experience or is it only a myth?

Dr. John Delap

I think GPs are very well skilled in modifying that kind of behaviour. It does take a little time but any experienced GP will respond in such a way that it is less likely that someone will come next time for an unnecessary consultation. There is always caution, one has to be cautious.

I thank the representatives from Deep End Ireland for attending. I am a GP for a deprived rural area as opposed to a deprived urban area. I understand exactly what the witnesses are saying. I have some points which might help us come to a conclusion about how we can improve our health service. The inverse care law is well-known. It did not just appear yesterday. Tudor Hart was mentioned as an iconic figure in the NHS in general practice, and he has spoken about the inverse care law for many years. It states that the people who need the care most have the least access to it. We are still trying to reverse the position.

We have a huge problem recruiting general practitioners in Ireland. We are educating fantastic GPs but, unfortunately, we are not able to retain them. Retention and recruitment of GPs is essential to reversing the inverse care law. Our contract is a big impediment because it is very fixed and inflexible. That is the first issue to be addressed. We need also to recruit practice nurses and staff to deal with all other community services. Perhaps a practice needs a nurse before it needs a second, third or fourth GP. My practice nurse sees 33% of the patients without any reference to me. That is a huge resource. How we go about recruiting and retaining staff is the key.

Primary care teams are a fantastic resource. Unfortunately, they are not staffed either. There is great difficulty in retaining staff. Instead of building 80 new primary care centres, we should fully staff 80 new primary care teams. Perhaps these primary care centres could be used for diagnostic services, as diagnostic and treatment centres. It is very difficult to attract GPs into primary care centres throughout the country. The barriers to joining such facilities can be great.

There is a backlog outside general practice. If a person is referred, there is a huge problem in getting services. Communication is a huge problem. Hospitals are not very good at information technology, IT. GPs are extremely advanced when it comes to IT. Communicating with hospitals is very difficult. We will hear more about the integration of primary and secondary care during our second session. It is an extremely important matter. It is vital that we discover how they managed to do that. I would like the witnesses' views on that and on the huge barriers that exist.

In the context of the inverse care law, information and education are key to preventing illness developing. That starts in schools and other educational facilities. That is a problem in deprived urban areas. There has to be a medical education programme in every school about smoking, drinking, unsafe behaviour and healthy lifestyles. This will not give a result tomorrow or the next day but it will do so in ten, 20 or 30 years' time.

I welcome the witnesses and thank them for their presentations. We speak of primary care as the bulwark of delivery of health care in the future. To date, it has been under-resourced, understaffed and under-utilised in many cases. During the Celtic tiger era we placed much emphasis on the physical structures of primary care, namely, the buildings. Let us be under no illusion, not every GP in the country embraced primary care teams. There was quite an amount of resistance. That was and is a problem because some GPs were not willing to engage with the process.

I have always felt that we are missing a link in the primary care strategy and it relates to diagnostics. There are primary care teams in some areas and there are primary care centres in others. Ultimately, all diagnostics have to go to the acute hospitals, through a referral to a consultant. Is there a link that we should establish? Rather than obsess about primary care centres in every community, we should have primary care teams and more regionalised centres for diagnostics. GPs should also have the facility to refer directly to a centre that is a step above a primary care centre where there would be other specialties and resources, as opposed to always referring into the acute setting. Once the referral is made, access depends on what comes through the emergency department of the hospital. There can never be a streamlined approach of elective referrals, surgeries, etc. Almost everybody ends up going to hospital through the referral process.

On the inverse care law and the need for resources in deprived areas, I represent a constituency which is a microcosm of Ireland and which comprises the most affluent and the poorest areas in an urban setting. I can see in people the differences in quality of health and the impact lifestyle has on health. There is a huge problem with diabetes, smoking, alcohol and poor housing, which give rise the outcomes we all know - cancer, cardiac problems, stroke and life expectancy issues. We simply are not investing the requisite resources. We are also making no effort on the preventative side. We all know that if people smoke less and have a healthy diet, they will have a better chance of living longer. The people who most need to hear the preventive advertising campaigns are least likely to hear them. Do we need to target resources, through the primary care teams, school, educational programmes and local authorities on real preventive efforts, as opposed to ticking boxes for a national campaign, knowing that the people who most need to hear the message will probably not be listening? There is a huge weakness there.

On the issue of salaried GPs, we are aware of the impact of the inverse care law, namely, that where resources are most needed, they are not in place. As opposed to weighted deprivation payments, would having salaried GPs in a problem area help? Would that be possible?

I am not criticising; I am making an observation. There is resistance, however, and every profession likes to have professional integrity and professional protection and they do not like the lines of demarcation to be frayed away at the edges. Prescribing nurses, for example, is something that can be resisted by some GPs. Are we using nurse specialists, practice nurses and community pharmacists fully as a resource and should there be a lot more emphasis on nurse specialists and practice nurses in primary care settings and in primary care teams?

If we are to establish primary care teams, I would like to think that there would be a possibility for GPs to specialise in certain areas. For example, demographic profiling of certain areas will show if there is going to be an ageing profile over time, so GPs would specialise in geriatric care. Could we be more imaginative in using the resources of the GP, the primary care team, nurses and nurse specialists? I have rolled observations and questions into one.

I am sorry for coming back in again but I want to refer back to the protocol-driven access to diagnostics. Perhaps the witness could clarify this. Is this a case where someone presents to a GP practice with a headache, and in order for them to be seen, one is able to prioritise? Could the witness explain what he means by that?

Dr. David Gibney

When I worked in the UK there was a protocol which was, for example, when someone has a headache then one must look for certain red flags. If there are no red flags one tries analgesia to see if the headache goes. There are certain steps to go through. If the steps are gone through and the headache persists and if there are no signs of anything acute, that case needs to go to hospital straight away as there could be some underlying pathology and there would be access to an MRI without having to wait to see a neurologist. That is what I mean.

In talking about diagnostics I believe it is pretty much agreed that an X-ray does not work in the community, or I take it that it does not work since it was tried in Ballymun and it was not resourced right. With regard to hospital trusts and the hospital at the centre of that, would Dr. Gibney consider that if there were a diagnostic wing which was attached to an acute hospital and not interfered with by an acute accident and emergency department, one could then send people from the community to that facility? It is shocking that a patient who clearly has cancer is waiting eight weeks to find out how bad it is. The patient in question is a Polish gentleman who has settled in Ireland. I met him at the weekend and I do not believe I would tolerate that wait if it were me. I have the luxury of private health insurance but it just seems horrendous that in a civilised country somebody who clearly has cancer would be left eight weeks to be told how bad it is. Are the witnesses saying if we had this set-up on site, attached to the acute hospitals and with radiologists, radiographers and all of those resources, that is the way to do it? If it is the way, is that too sparse to deal with the lad down in Clonakilty or wherever? Is it too little? Do we need more than that to serve the people in rural areas? Would the witnesses consider that the way forward, having a wing attached to an acute hospital for primary care referrals?

Professor Susan Smith

I will start with the question on salaried GPs as it was mentioned earlier and it links to one of the Deputy's earlier remarks about what would one choose if one could only choose deprivation weighted payments or specific resources. The truth is that I do not believe there is any one answer to any of this. Salaried GPs is a great idea but they have to work in a practice, so it is very unlikely that a centre could be set up that was only staffed by salaried GPs. They would need to have the kind of integration with the rest of the system such as GMS contracts. They would be working with GPs with GMS contracts. It is part of the solution but it is not the only solution. The committee has spoken about barriers and GPs not participating fully in primary care centres. My colleague, Dr. Gibney, has good experience in addressing those barriers.

Dr. David Gibney

Some of the barriers are to do with cost, no uniformity around cost and who pays what. It seems that different people pay different amounts moving into primary care centres. We were in an older health centre which was lucky enough to be under the national agreement, created under the John O'Connell deal, where no rent was to be charged to GPs working in groups who worked in health centres. We still work under the aegis of that agreement which we had when we started off. We have heard statistics about one GP for 2,500 in deprived areas compared with 1,600. My practice size is 2,500 but we can employ 1.6 doctors because the rent is not an issue. There are ways of attracting people into primary care centres. In areas of blanket deprivation it is different from areas of more scattered deprivation. In areas of blanket deprivation it is very useful to have everybody co-located. It can work differently but that model is useful.

Dr. Edel McGinnity

It is important to note that while we are looking for more resources, we are actually looking for our patients to have the same access as everybody else. For that to happen there needs to be a slightly different approach to those patients. In our experience it is true that there is resistance to primary care teams, but not as much in areas of disadvantage because we see the importance of the teams. General practice is a very broad church. There are many different models and ways of doing it but there is a lot of evidence to support the argument that GPs are more likely to integrate with primary care teams in these areas. There should be special measures for these areas, a bit like the DEIS schools system in education, to bring everybody up to the same level.

With regard to the diagnostics, there is a possibility of my local hospital, Connolly Hospital, setting up a diagnostic unit in one of the primary care centres in our area. I am in favour of anything that increases my patients' access. However, it does not have to be in a primary care centre. As Deputy O'Connell has said, if it was ring-fenced, why not just keep it in Connolly Hospital and make sure there are slots dedicated for GPs and an X-ray room that only takes GP referrals.

The doctor knows what would happen. It would be snaffled by accident and emergency and what comes in through the other side of the hospital.

Dr. Edel McGinnity

Yes, there is always that; it is true. Communication was mentioned, and on the positive side, GPs, as everybody knows, are outside the system and off doing their own thing a lot of the time. That has led us to have communications problems within the HSE structures in particular, but Healthmail is a new ICGP promoted e-mail system where we can e-mail about our patients. Previously it was difficult for GPs to do that. That system has completely transformed my working life because I can now e-mail all my primary care colleagues and all the Tusla social work system. Those calls that I was getting in the middle of patient consultations are much reduced because I can now work with this e-mail system. As Deputy Harty has said, we are well ahead with the IT. It fascinates me that some of the hospitals spend a fortune with all of these validation letters saying that a patient did not turn up for an appointment. It is not just validation letters. Our local hospital now sends us a letter to say that someone is on a waiting list. I want to know when their appointment is so I can phone them about their appointment. However, I cannot find that out because the hospital will not deal with me by e-mail, but we are working on it.

In fairness to the HSE, when its IT group was before this committee last week, it gave a commitment that electronic referrals would be facilitated in all hospitals by April of next year. We will be holding the HSE to that.

Dr. John Delap

It is worth pointing out that the Department and the HSE have transformed their electronic communication and in particular the Healthlinks system whereby we get reports electronically from the hospital that can be integrated at the click of a switch into the patient's file. That has transformed life for us with regard to handling data. It has been a marvellous success.

Dr. Edel McGinnity

On the question about prevention campaigns and the very valid point that they often do not reach the people who most need them, we reach those people every day. We are more than trained to deal with prevention.

We spend much of our time doing that work when we are not dealing with their acute problems. Our practice nurses are fantastic at it. Had we more time for our patients, we could do much more of it. It would be targeted at the person in front of us, his or her lifestyle and what would work for him or her in terms of weight loss, stopping smoking and so on.

That is a valid point and I have often thought about it. Having a primary care centre in the middle of a community makes an important statement and allows for many other activities to take place, for example, evening courses to help people to stop smoking. It facilitates a greater approach to health promotion.

Will the delegates comment on how the recruitment and retention of general practitioners, GPs, can be managed?

Dr. John Delap

The difficulty is that the model we would promote does not apply in west County Clare. The primary care centre with a primary care team operating within it is the model that works well in deprived urban areas. The teams that work well tend to be in areas where there are primary care centres and two or three practices. Organising a primary care team with disparate practices spread across a large area is more difficult.

We do not have the same difficulty in recruiting GPs to our practices because we are relatively well resourced and well organised and people are keen to work with us. However, I do not have an answer as regards the person who works single-handedly from his or her own premises in a rural area. I do not know how that circle can be squared.

Dr. Edel McGinnity

It is important to note that there have been significant cuts in funding for general practice in the past ten years, by as much as 40% in some cases. Only 2% of the health budget goes to general practice, whereas 95% of all health care is provided in the community. The United Kingdom spends 8% of its health budget on general practice. The reason GPs will not work in that environment is straightforward - practices are not viable in small rural areas. There is a fixed rate per patient. If there are only 500 people in a village, there will not be enough patients to sustain a practice. That is the problem.

In the NHS one can only visit a GP for ten minutes. Its primary care system does not seem to be working well in terms of the amount of time patients can spend with their GPs. Waiting times to see a GP seem to be extending. All that glistens is not gold in this context.

Professor Susan Smith

No. That has to do with universal access. Having universal access and equity poses a challenge.

If one has universal access but does not expand capacity, those who need it most will suffer the most.

Professor Susan Smith

One of the solutions to retention in Ireland is providing targeted GP training in areas where GPs are needed. There is a training scheme in place in the north inner city of Dublin led by Dr. Austin O'Carroll. Many people internationally say that, if people were trained in the right areas, they would be more likely to stay and work in them.

As mentioned, it is difficult for a new GP to do that, unless there is funding behind him or her. That is why there is such a strong case to be made for having State-funded primary care centres. A couple of years ago I spoke to a group of trainee GPs who were keen to be at the cutting edge of medicine, but it was not possible for most of them to do so. What would they do about having premises? As stated, running a practice does not stack up, even if one has premises.

Dr. Edel McGinnity

An issue is that, given the volume of work and the complications in working in areas of disadvantage, there is a high rate of GP burnout. A committee member mentioned that he or she did not see us often. We are all in practices where we have the support of colleagues. It is not possible to work as a GP single-handedly in a disadvantaged area. One needs considerable support from one's practice and primary care teams. That is why the old model whereby a GP set up shop in a house on an estate does not work. It happens often in Blanchardstown, but GPs cannot manage it. As Professor Smith stated, one cannot pilot a whole team with salaried GPs. It must be based on existing practices.

As an aside, I have a question about an issue that is arising frequently. I mentioned demographics and the fact that we were all getting older. There is a further requirement for us to address the issues of nursing home support, geriatric teams in the community and retaining people in the home care setting. We conducted some research and I have now seen a great deal of evidence when it was just anecdotal until recently. Locum doctors or out-of-hours GPs are handling out-of-hours calls for many nursing homes. I am not saying it is happening in every case, but there is a high tendency for the elderly person to be referred to an emergency department. Can we be imaginative in any way in addressing this issue? When one speaks to the consultant in the hospital, he or she says the person should not have been there and that he or she needed to be on IV drip and antibiotics and should have been retained where he or she had been. There seems to be a lack of capacity in the out-of-hours service. It is fine when the GP calling knows the patient in the nursing home, but is there any way for us to be more imaginative in dealing with this issue? Being moved from a nursing home to an emergency department where there is a great deal of trundling, unnecessary agitation and so on, only to be kept for a number of days to receive low-level treatment before being sent back, places a major burden on the patient which is causing difficulties. Hospital managements state it is a significant issue. I do not know whether it is a significant issue in the delegates' areas, but if an area contains a large number of patients in nursing homes, there must be something more than an out-of-hours service.

Professor Susan Smith

There is a considerable opportunity for general practice to provide structured care in those settings. In my practice in Inchicore we provide a care service for several nursing homes. It is also a way for GPs to diversify in their clinical activities in order that they are not always engaged in face-to-face consultations with the same patients. Some might spend a half day on a ward round in a nursing home. It is important because conversations about individual patients' choices can be had during the day in order that, if something happens in the middle of the night, a patient has already decided that he or she does not want to sit on a trolley in an emergency department for 12 hours and instead wants to be treated in the nursing home or wherever else. This requires a resourced, structured care service in order that patients will be a part of a named GP's practice and that the GP will monitor what he or she does with them. GPs have the skills to do this work.

Yes, they have the skills. The problem is that there are not enough resources available or such GPs.

Professor Susan Smith

Time is the issue.

It is about time and resources. If one had them, one could attend a nursing home for a half day and have those conversations and it would be significantly less likely that a person would opt to transfer to an emergency department, which might not be the most appropriate place for him or her. One cannot necessarily expect a locum to make that decision if he or she-----

(Interruptions).

It is fair to say the contract does not cater adequately for out-of-hours services.

Professor Susan Smith

When we discuss the issue of weighted deprivation, it is all about the contract. We hope to advocate for a strengthening of the contract in respect of resourcing based on need.

That contract is being negotiated.

Professor Susan Smith

Yes.

What is the deadline for its completion?

Professor Susan Smith

We are not involved in the negotiations.

The delegates are not allowed.

May I make one more point?

It relates to recruitment and I am sorry to belabour the point, but Professor Smith will understand the position. The first cohort of graduate entry medical students are qualifying as GPs. They carry a large burden of debt, having put themselves through medical school at a cost of €100,000 or €120,000. Unless that issue is addressed and a system introduced that will allow them to offset that debt by deferring it over a long period or the Government taking it over, we will lose these graduate GPs. Some 33% of the GP population are over the age of 55 years. Recruitment is essential if they are to be replaced. Dr. Delap may not have a difficulty in recruiting into his centre, but if 33% of GPs disappear in the next ten years, from where will their replacements come?

If universal primary care is to be introduced, we need to double our GP numbers, not lose one third.

Dr. David Gibney

We do not have a problem with recruitment. However, we cannot recruit any more because we do not have any space. We are only seeing 9,000 or 10,000 patients and there are more than 20,000 in Ballymun. There are many who cannot get near our centre. We are absolutely maxed out from the point of view of using every room. We are even double-rooming. We have done everything we can but we do not have any more space. We need more space. People like working. When practices are well-resourced and they are working with primary care teams and good nurses, doctors will be attracted to work in those areas because they feel supported.

Dr. Edel McGinnity

On things that could take place in general practice that are currently done in hospitals, we concentrated a lot on diagnostics, but there is huge expertise among the GP community. In my practice, we insert a lot of Mirena coils. It costs a fortune to perform such insertions in a hospital setting. We take referrals from other practices in the area to do it. We have a GP colleague in Blanchardstown who takes referrals - when he is funded - for minor surgeries such as those involving the removal of skin lesions. That is incredibly cost-effective compared to sending the person involved to hospital. There are lots of services such as that which GPs can provide if we get the-----

I have noticed, from following sport, that there are fewer GPs nowadays stitching or suturing than in previous times. Take ingrown toenails, for example. Traditionally, a problem with an ingrown toenail would have been dealt with by a GP in his or her practice. There seems to be-----

Dr. Edel McGinnity

What is the payment for stitching?

I am talking about the GP's ability. It does not really pay-----

Dr. Edel McGinnity

It is approximately €40.

Dr. David Gibney

It actually costs money to do it. It should be done in general practice. One of our doctors went off and trained in minor surgery. However, there is a small payment - I cannot remember it - of €20 or €30 for doing it, but one has to provide all the instruments and the suturing material, so we actually ended up paying money to perform the minor surgery. It just was not viable.

Dr. John Delap

The other difficulty is that if a practice has two or three doctors with 6,000 or 7,000 patients, it will not have enough throughput to keep their skills up to date for such procedures. It must, therefore, be done on a wider basis.

The witnesses spoke about the distribution of resources. One of our work streams will examine the area of resource allocation. We propose to do a kind of socioeconomic profile of each of the community health care organisations, CHOs, and then look at where staff are allocated across primary care in order to identify where the big gaps exist. Ideally, we should be moving towards a situation where we have a transparent and objective resource allocation model that can be established in the Department and used. The bones of such a model is there. We should be using that objective resource allocation model when it comes to allocating nurses, physiotherapists or GPs so that we know the facts. The committee is very much committed to an evidence-based approach to policy development.

A number of issues were raised, especially later on, that relate to the terms of the contract. What kind of influence do the witnesses have in their representative organisations - whether it is the Irish Medical Organisation, the National Association of General Practitioners, etc. - on the kind of issues that are important to them in the context of a new contract?

Professor Susan Smith

We have met all the people who are doing the negotiations and presented to them the same information we have presented to the committee so we believe they are aware of those issues.

Dr. David Gibney

It is part of the briefing we have seen. It is part of what they would like to see in the new contract, which is that areas of deprivation and rural areas would be treated slightly separately and that there would be an awareness of the different needs. It would not be a one-size-fits-all approach.

Does Dr. Gibney think there is an acceptance that there is a need for a weighted system of resource allocation?

Dr. David Gibney

I think so.

Professor Susan Smith

Most doctors would find it hard to argue against matching resource to health need-----

Professor Susan Smith

-----so I think they would accept that.

That is encouraging.

The time limits are important for us because the GP contract will be the foundation of primary care for the next number of years and we could be reporting after the contract is agreed, which is-----

We do need to bring that forward.

The contract could be agreed in advance of us reporting. I know they both may be slower than we think but, at the same time, it is not a risk we can afford to take.

That is an important point and we should list it for discussion later on.

On the obsession with the deprivation index, is there any reason people might be stigmatised as a result of being in a sort of a higher-risk category? Normally, GMS patients are all the one and the same and the GP gets a certain payment. The HSE issued a card to those who contracted hepatitis from contaminated blood or blood products and there was some name on it, which I cannot remember, but it was inappropriate. Will the patient be any more aware?

Dr. Edel McGinnity

He or she will just have a medical card.

I am just making sure that they do not get a card stating "high risk" or-----

Dr. Edel McGinnity

In the same way the primary care reimbursement service, PCRS, allocates a different payment according to age, it will be very easy to integrate deprivation status into that and it will just come out in the payments. The patients would not have a clue.

Finally, I call Deputy Joan Collins.

I am sorry I missed the witnesses' presentation, which is why I did not contribute before now because I was not going to make comment on a conversation I did not hear. On GPs coming out of colleges with huge debts of €120,000 or so, how do we keep those individuals in the country? Perhaps the committee needs to look at a strategy, from the point of view of salary, to deal with that problem. If they spend ten or 15 years practising in communities, perhaps that would entice them to stay. It would not be a huge burden.

There is a great deal of scope for review of that kind of arrangement.

Professor Susan Smith

Deputy Harty mentioned retention and I feel we have not really answered his question. I do not know that there is a clear answer. However, this is not just a problem for Ireland. There is a huge issue in North America around family practice as well because graduates there have even higher debt than their counterparts here and they simply gravitate towards high-earning specialties. It is about workforce planning. We will have to come up with solutions to address what will be a crisis in the next decade in terms of the availability of GPs.

I thank the witnesses very much for their presentations. They were exceptional. What the witnesses have said will leave a strong impression with us in terms of our recommendations for the future. We thank them for their time - they have been very generous with it - and for answering all of the questions put to them so thoroughly.

Sitting suspended at 10.50 a.m. and resumed at 11.10 a.m.