Deputy Byrne gave notice that he would raise on the Adjournment the subject matter on Question No. 2 of 1st July.
Adjournment Debate: Medical Practitioners.
I am raising this matter because it is important that we make sure that sufficient practitioners will be available to implement the new Health Act. With this in mind the question was tabled to find out if accurate research had been carried out by the Department to ascertain the number of general practitioners who would be available. From the reply and from the supplementaries that followed it would appear as if the Department are not fully informed about the availability of general practitioners, particularly in rural areas. Prior to this question being tabled, a number of questions were tabled which related to dispensary appointments in rural areas, particularly along the western seaboard, to find out which positions were vacant, which were permanent appointments and which were of a temporary nature. Figures for these were not available. It would appear, therefore, that no accurate figures are available regarding the number of general practitioners who are in active practice at present. I do not think this can be disputed. The latest figures available to the Minister were for 1966 so that when the Act comes to be implemented the figures will be well over five years old.
Recent reports have come to light through different medical organisations which show that the same number of doctors are not entering the general practitioner field now as ten years ago. It is of the utmost importance that we should know, when implementing this Health Act, the number of doctors who can be called on and the degree of activity which each doctor can give. The figure here is for 1,300 active general practitioner's in 1966 and in my opinion it is not reliable enough because from the Minister's reply there does not appear to be any statistical solidarity for the figure. It appears to have been obtained as a result of a routine spot survey of some sort by two doctors. The Minister stated that there were probably only 12 fewer doctors in 1969 than in 1966. We have to remember that doctors are not entering general practice in the numbers they were some years ago. As well as that, in regard to the 1,300 general practitioners mentioned there are different degrees of activity for each general practitioner. This is very important because some practitioners provide a 24-hour, seven days a week service, others a five-day week service, while others would be working on a month on month off basis, where they would be in semi-retirement. Other doctors would be doing occasional locum surgeries.
We do not know, therefore, the number of fully active general practitioners who would be available for the health services. That is in relation to the whole country but in the rural areas we do not know what the number of registered general practitioners is. Dublin city, Dublin county and areas adjacent to large urban complexes will be catered for reasonably well in regard to general medical services under the new Act but it must be remembered that the most important section will be the front line troops, who will be the patients and the practitioners. If the scheme cracks up at this level, then it will be a failure. In many areas the new health service will not be implemented. A couple of weeks ago, in reply to a question by me, the Minister said that he hoped to introduce the choice of doctor scheme on the 1st April next. I contest this. I do not think the Minister is in a position to promise a choice of doctor service in rural areas. I do not think that the Department have carried out sufficient research into the number of vacancies, the population, or the number of doctors per head of the population in the more remote areas.
I would ask the Minister to institute, between now and April, a register of general practitioners which could then be compiled annually. This would serve three functions. It would give us immediately the number of doctors in active general practice. It would give us the number of doctors who are writing prescriptions and in this way would combat what the Minister referred to before, the forging of general practitioner prescriptions. Thirdly, it would form the basis for accurate statistics in the future. There is no doubt that we will have great difficulty getting doctors into the remote areas for different reasons. There are many factors involved. One is that it is very difficult to get a settled general practitioner to pull up his roots and plant them in another part of the country. As well as that, the social amenities in these areas, as well as the emigration, are not attractive. When people emigrate from one part of the country it is difficult to get other people to replace them.
The Minister must have a pool of general practitioners available in order to operate the health services. Bearing this in mind and also the recent figures produced by some universities that certain students, potential doctors, have not been able to obtain places in medical schools, I would call on the Minister to introduce a State grant or scholarship which would enable suitably qualified students who had passed their pre-medical examination to enter medical school and proceed with their medical studies immediately. Then on completion of these studies and their immediate post-graduate training they would be in a position to give back approximately three years to the State practising in outlying areas. This would serve two purposes. A student would receive the medical training he and his family desire and he would then be of great service to the country, repaying the cost of his education by working for two years after he became fully qualified. This is a system which has already been operated by other people. This system is carried out in this country by an organisation from Great Britain that recruits students here in their second medical year. The organisation pay the fees and give a living allowance to the student who must in return give five years service to that organisation. The organisation recruit approximately 50 students per year, most of them being Irish.
There appears to be a lack of communication between the universities in this country, the Minister for Education and the Minister for Health as regards medical education. I would ask the Minister for Health to set up a committee to carry out an investigation as regards the logistics that would be necessary for the implementation of the health service in the rural areas.
The Minister for Education has said that we are producing too many doctors. However, there are very many areas throughout the country where there is no dispensary service available or any service available for persons in the lower income group. I have put down questions to the Minister asking for information regard the number of dispensary posts, permanent and temporary, in Counties Cork, Kerry, Clare, Galway, Sligo and Leitrim, to name but a few places. The Minister did not answer my query. However, the figures are available in some form to the local authorities.
The percentage of medical card holders in the country is 30, and in some counties that have not got full dispensary appointments the figure goes as high as 40. The number of persons who will qualify for medical services under this Health Act but who will not have the services of a doctor will be very high. The Minister should instruct the officials in his Department to investigate the number of students entering medical school, the number qualifying and the number who enter general practice, plus the number of areas in the country where there will not be a choice of doctor. When those figures are available the Minister will be in a position to consider the advisability of a State grant or scholarship which I have suggested to him and which I believe is the answer to the problem that is facing his Department.
This problem is indeed great. The Minister is introducing a Health Act and while, statistically, he has sufficient doctors there are not enough doctors in the country areas. I have come here not merely to criticise the Minister but to offer a solution and what I have suggested has worked successfully for organisations outside this country who have been able to recruit doctors from the universities.
It must be admitted that choice of doctor to replace the dispensary doctor is unrealistic because the manpower is not available and we must consider some way of rectifying this matter. If we are producing a sufficient number of doctors, why are they not going to practices in rural areas? It is possibly that the conditions offered are not attractive enough, particularly where the doctor has a family and must consider the matter of education for his children, and also the fact that the post can be terminated after one year or 18 months will not entice a doctor to accept those posts.
The advantage of offering a State gant or scholarship to the student is that he does not have the restrictions imposed on him that perhaps a married doctor would have and, consequently, he would be prepared to work in the remote areas or in the islands off the west coast. I held a dispensary post in rural Ireland at one time and I am aware of the difficulty of attracting medical personnel to outlying regions. I consider the solution I have offered the Minister worth investigating.
I do not agree that we are producing too many doctors and I do not think that this should be stated here in the House. Any student in this country who wishes to enter medical school should not be excluded from doing so because the Minister for Education has suggested there are too many doctors, particularly when the facts are that there are not sufficient doctors in rural areas. We should offer an incentive to doctors to work in those remote areas and I think it is a sad day when the Minister for Education can get up and say——
We cannot discuss the Minister for Education. The Minister for Health is the Minister responsible in this case.
How much time am I allowed to reply?
The Minister is allowed ten minutes, the Deputy 20 minutes.
There is a definite need to increase the number of doctors in rural areas. The Minister is well aware that there are many areas at present that do not have any form of general practitioner service and there are many sections of the population who only have a fill-in type of medical service. The Minister is introducing a health service and not only will there not be a choice of doctor but there will not be enough doctors to run the service efficiently. People in rural areas who are without medical services read with amazement statements that we have too many doctors in this country. I would call on the Minister to investigate fully the whole matter of medical education in Ireland.
As a layman on this subject, I should be very grateful if the Minister would tell us and medical practitioners throughout the country whether it will be possible in the scheme he now proposes that general practitioners' services in the remote areas will be available. Can the Minister let us know if he is happy about the situation now obtaining? My information is that no matter what inducement is given to dispensary and other doctors they are not prepared to work in those areas.
First, I wish to reject everything Deputy Byrne has stated and to inform the House that my Department are taking full cognisance of the problems involved in providing choice of doctor and are fully alive to the situation. Moreover, the Deputy has grossly exaggerated the position in the country with regard to the number of doctors who are now available. There are approximately 900 general practitioners in the country districts. We have made inquiries from county medical officers and we find that between 1966 and 1969 some 106 doctors joined the service in those areas and 131 doctors have left. There is therefore a reduction of 25 or 2.8 per cent of the total number of doctors in the areas outside Dublin. That is not by itself a matter of crisis character but naturally we have regard to the position in the future.
We also examined the whole position with regard to district medical officers and general practitioners in private practice throughout the country and in Dublin. It was found that approximately 306 out of 1,295 doctors registered will reach the age of 70 by 1981. That does not take account of those who might die within the period. We do not have the numbers of those, but it indicates that there is an entry of doctors into the general practitioner service. I think 106 doctors entered the service in the last three years. Although there has been a slight reduction, there is nothing like a crisis at the age when doctors retire, although admittedly quite a number of doctors are 60 years or coming to 70 years of age.
A recent survey in Great Britain showed that there was one doctor to every 2,430 of the population. Here the proportion in Dublin city and county is 1,990 and in the rest of the country 2,331, so that the average for the whole country is 2,220—that is to say, general practitioners per 1,000 of the population. Comparison is dangerous because the British report does not take account of part-time doctors whereas we include part-time doctors. One cannot, therefore, make an absolute comparison, but one can say that the ratio of doctors to population both in the country and in Dublin is certainly not unsatisfactory in relation to the position in Great Britain. I have pointed out that we in the Department are aware of the position; we are not sitting back and doing nothing about it.
Deputy Byrne referred to the question of the Minister for Education's views on the number of doctors who should be trained. The Minister for Education has not suggested that fewer doctors should be trained in this country. We train about 250 doctors a year, of whom something under 100 are required for service in this country. The medical profession, the nursing profession and the priesthood are our three great vocations and I would not want to disturb them in the least. We do not propose to do that, even though the cost of training doctors who are going to leave for service abroad and taking people who come from abroad to be trained as doctors is very high. I know the Minister for Education has not taken any decision to alter this in the future.
In so far as the future position is concerned when the choice of doctor scheme comes into operation, as Deputy Byrne well knows, the permanent district medical officers will be guaranteed their income and will retain their positions. They will be guaranteed their income with the usual twelfth round increases. Temporary district medical officers will be able to partake in the choice of doctor plan for a period and so far as those areas where there is not even a temporary district medical officer are concerned the service is being performed by doctors in neighbouring districts. I have not had any complaints of note that the service provided by these doctors is totally inadequate. From time to time complaints come to me and occasionally there are Parliamentary Questions but I have no serious complaints from remote rural areas where service is being provided by temporary district medical officers or by permanent district medical officers in the contiguous areas. With regard to seeing what we can do in rural districts, we intend to examine all the possible propositions. Deputy Byrne should be aware that we have offered extra pay for working in remote rural areas and this now exists in the Gaeltacht areas and some other areas. We intend to offer positions in the towns in the western areas on condition that the doctor who is appointed will do a stint in a rural area. We intend to examine every possible plan to maintain the general practitioner service in the country.
I regard the general practitioner service as absolutely vital for one reason which may not be apparent to the House. About one-third of all the general practitioners' duties relate to the mental condition of patients. There is not the remotest hope of being able to appoint in Great Britain or America enough psychiatrists to do the work of general practitioners. In many cases the first examination of a person who has some kind of mental trouble or difficulty will be by the general practitioner who will then refer the patient if necessary to a psychiatrist, a psychiatric social worker or some other person who will be more suitable to examine the patient's condition. For that reason alone the value of the general practitioner service is very, very great, quite apart from the medical service offered and all the arguments can be adduced in regard to that matter. Deputy Byrne may be satisfied that I have not failed to read the voluminous report from the Royal College of General Practitioners in regard to the future of the general practitioner service which is not only a problem here but a problem in other countries. It is even becoming a problem in countries with large urban populations with massive practices. It is not unique to this country.
The arrangements for the apprenticeship of newly-graduated doctors, helping them to do further training and encouraging them to go out into country districts, are all matters being pursued by my Department, as is also the very important question of ensuring refresher courses for general practitioners. We intend to study that just as soon as we have completed the arrangements for choice of doctor.
I am sure Deputy Byrne will approve of my action in this regard. I notice we have had a great number of commissions of inquiry whose reports have been implemented since they were published. We have had reports on the mentally handicapped, mental illness, child health services, the care of the aged and the future of the hospitals, but at the moment there is no important committee dealing with medical health services. I decided two months ago, with the consent of the Minister for Finance, to have an inquiry, probably in the form of a working committee, into the future of the general practitioner service in this country because the reports I have read from other countries do not relate to conditions here. Whilst we can get a good deal of advice from the research work done by the Royal College of General Practitioners, we have particular problems here. I decided therefore to have an inquiry set up in connection with the start of the choice of doctor scheme.
In the meantime we are going on assembling more information of the kind that will be utilised by this inquiry committee. We have assembled a good deal of it already; we are making further inquiries about this; we are marking and examining areas where doctors are scarce and we will go further into the examination of the ages of doctors in the service. In that way I hope we shall be able to come up with some favourable policies leading to the advancement of the general practitioner service here but bearing in mind that it is going to be difficult to attain. If anything like three-quarters of the Todd Report is implemented there is going to be more and more encouragement for doctors to specialise, in which case we shall also have to look at the possibilities of developing group practice not only in Dublin but in the main towns of the western areas. That will be a further subject for examination, particularly examination with the Medical Union and the Irish Medical Association in so far as there are implications arising from group practice in relation to the choice of doctor scheme.
I hope I have now satisfied Deputy Byrne that we are fully alive to all the questions he raised.
The Dáil adjourned at 5.30 p.m. until 3 p.m. on Tuesday, 21st July, 1970.