asked the Minister for Health the steps he is taking to avert a complete breakdown of the GMS following the resignation of a large number of pharmacists and the announced intended resignation of many doctors.
29.
Ceisteanna—Questions. Oral Answers. - General Medical Services.
28.
asked the Minister for Health if he will make a statement on a letter (copy supplied) from the Irish Pharmaceutical Union regarding members of that union who have decided to withdraw from the general medical services scheme.
With the permission of the Ceann Comhairle, I propose to take Questions Nos. 28 and 29 together. I propose, with the indulgence of the House, to set out in some detail the present position about the difficulties which have arisen in relation to the continuing provision of their services by doctors and pharmacists in the general medical service.
So far as doctors are concerned, they are paid fees per items of service. This has been in operation since the scheme commenced. A fee of 80p is paid for a visit by a patient to the doctor's surgery in normal hours. A higher range of fees applies to consultations in the patient's house and higher fees are specified for work outside normal hours and for work at night. The amount of the fee for domiliciary consultation depends on the time at which it is made and the distance the patient lives from the doctor's residence. The maximum fee payable at present is £5.25 for a call made between midnight and 8 a.m. to a person living more than ten miles from the doctor.
In June last, the medical organisations sought an increase in the basic fee from 80p to £2, an increase of 150 per cent, with pro rata increases in other fees. If this claim were conceded, the highest fee would have been £13.13 instead of £5.25. After I had considered the claim, I informed the medical organisations that I was not willing to concede it and by agreement it was referred to arbitration in accordance with the terms of the agreement made with my predecessor. The arbitrator, having considered the claim, issued his award on 22nd November, recommending a basic surgery fee of 90p and increases in the other fees. He recommended that the fee for a domiciliary consultation during normal hours in an urban area should be raised to £1.35 and that the maximum fee should be raised from £5.25 to £7. These higher fees would operate retrospectively to 1st October, 1973. The medical organisations informed me on 10th January that they had rejected the arbitrator's award which I would, in accordance with the normal practice of this Government, have been willing to accept.
I met the representatives of the medical organisations on 16th January and explained to them that, in relation to the period covered by the arbitrator's award, that is, from 1st October, 1973, to November, 1974, I could not justify going beyond his recommendations. I did, however, make it clear that I was willing to review the fees in relation to increases which had taken place after the date of the arbitrator's award in wages and salaries under the national wage agreement. This, I might mention, is a fundamental change in earlier practices whereby fees, when fixed, operated for a long time without revision.
I set out the effect of these changes in a detailed letter which I issued to both medical organisations and a copy of which I have placed in the Library. The net effect of the changes which I proposed to make in the fees would have been that, from 1st March the basic surgery fee would be increased by 34 per cent to £1.07 and the maximum fee would rise from £5.25 to £8.18, an increase of 56 per cent.
It may help Deputies to put the matter in perspective to know that, from the existing ranges of fees, the average gross income of a doctor, in the year ending 30th June, 1974, was £5,280, in respect of an average of 950 patients. A full-time practice would contain about two-and-a-half times that number of patients. That amount would, under the arbitrator's award, increase to £6,055 and my later proposals would mean that a doctor could earn £7,323 in gross income in the year after 1st March next.
This average sum of £7,323 would be gross remuneration from the general medical services. A deduction has to be made from it for practice expenses but I would emphasise that it is part-time remuneration, covering services for about one-third of the population. In addition to it, general practitioners receive private fees in respect of the remaining two-thirds. They may also receive payments in respect of items not covered under the general medical services, such as payments under the maternity and infant care scheme, employment on a part-time basis in hospitals and fees for social welfare certificates.
As I have said, the practice in the past has been to review fees at a yearly or longer intervals. In agreeing to make upward revisions in fees in accordance with changes taking place in salaries under the National Wage Agreement, I was taking a new step and one which I had hoped would be accepted by the medical profession as an honest attempt to meet, in a reasonable manner, the claim which they made, without departing from the principle of accepting arbitrators' awards where they are made. It is a matter of regret to me that the councils of the medical organisations should have rejected this approach and advised their members to submit resignations from the service. However, my letter setting out my position has been sent to participating doctors and I hope they will consider it carefully before taking final action.
In the meantime, I think it is important that contact be maintained with the organisations. Accordingly, my Department have invited the secretaries of the organisations to an early meeting mainly with a view to being quite clear on the decisions taken.
To turn to the pharmacists, they are paid on the basis of a fee for each item dispensed, plus a refund of the cost of drugs and an amount in respect of containers and other costs. These fees were negotiated by my predecessor at the time the scheme commenced. The current inclusive fee is 20p per item dispensed, 17p being in relation to the provision of the service and 3p being an amount calculated to cover the cost of containers, obsolescence and capital involvement. In June last they made a submission that the fee thus negotiated was entirely inadequate and asked for a new fee of 78p, of which 60p would be for professional services and 18p to cover container costs, and so on. The net effect of this claim would have been to increase the total expenditure on fees for pharmacists from £1.75 million annually to £6.78 million.
A number of meetings took place on this claim but the pharmacists did not satisfy me that it was reasonable. To meet circumstances just such as this, my predecessor had written into the arrangements for the scheme that, where the two sides could not agree on an adjustment of the fees, the matter would be referred to an agreed arbitration board. On 4th October last, I put it to the pharmacists that this was then the best course to follow. It is a matter of regret and surprise to me that they decided not to go ahead with the obligation thus accepted with my predecessor, and decided instead to recommend to their members that they should resign from the scheme. The Pharmaceutical Union have collected resignations from members and submitted them to health boards on 21st January.
It appears that approximately 79 per cent of the pharmacists in the scheme have submitted their resignations, the percentage of those who have resigned varying as between health board areas.
I would make it clear to the House that I would not be opposed to some adjustment in the pharmacists' fees. As in the case of the doctors, I accept that they have fallen out of line with increases to others given in accordance with the national pay agreements. However, it did not seem appropriate to open discussions on this matter with the pharmacists, having regard to the magnitude of their claim and the acceptance in the agreement that disagreements should go to arbitration. I thought then, and I still think, that, both from their point of view and mine, the speediest resolution of the outstanding issues can be achieved through an agreed arbitration. It is, I would mention, quite common practice for the official side to ask that a claim should go to arbitration without an offer being made. I could cite many recent examples of this.
In notifying me of their decision, the Pharmaceutical Union have said that they are available to meet me at any time. I propose to ask them to meet me soon to discuss the situation generally.
Deputies will have received a letter dated 28th January, 1975, sent by the secretary general of the Irish Pharmaceutical Union to members of both Houses of the Oireachtas. I do not propose to discuss all the points made in this letter. Many of them are, indeed, points which have been made in the discussions with the Department and could appropriately be made to an arbitrator. I would say, however, that a guarantee was never given that no more than 900,000 persons would be eligible for the scheme. What was agreed jointly was that the conditions accepted would relate only to a situation where there would be "no significant change in the percentage of population now eligible for the service". The percentage has increased somewhat but whether in the context of the agreement the increase is significant is arguable. It must also be remembered that the population has increased in the meantime, so that some increase in the number covered could have been expected even if the percentage had remained absolutely static.
Again, I am afraid I have not been very much impressed with the argument which was also put forward in the negotiations, that the Department had insisted that the scheme was a simple one and that this had turned out not to be the case, thereby justifying a very big increase in fees. The negotiators from the pharmacists should have known very well what was involved in the scheme, because it was discussed in detail over very many meetings. Many pharmacists had experience in the dispensary service and this experience should also have helped them in understanding what was involved. I would mention too that in the practical arrangements for the scheme, my Department did everything possible to make paper-work and administrative commitments as simple as possible and that, during the operation of the scheme, there has been ready willingness to discuss these with the pharmacists and to adapt them where this is possible.
The union's letter states why they decided not to "proceed with the process of arbitration". I think it is as well to put on record for the House the actual provision in the original agreement made by my predecessor for review. This was:
The fees proposed in the foregoing paragraphs will operate for at least one year after the full implementation of the scheme and will be reviewed not later than two years after the initial introduction of the scheme. The review will be carried out by the Department of Health in conjunction with the joint negotiating committee and, if agreement is not possible at that level, the matter will be referred to an agreed arbitration board. The board will have authority to take into account all relevant factors including charges in general price and income levels. The arbitration board will also have power to make a retrospective adjustment in the fees if the experience in the operation of the scheme satisfied it that this is appropriate.
With provision for an arbitration board with such a wide remit as this, it is not easy to accept the union's reasons for not going to arbitration.
I would now turn to a fundamental issue relating to the pharmacists' participation in the scheme. The 1966 White Paper on the Health Services and their Further Development left open two possibilities for supplying drugs and medicines to those in the lower income group—issue through public depots or issue through private pharmacies. The latter was ultimately accepted on the understanding that it would be an economical way of distributing these drugs and medicines. The extra cost of meeting the claim now made by the Irish Pharmaceutical Union, whatever the merits of that claim, would be such that I would have to look again at the choice between the two possible alternatives for issuing drugs and medicines which was made by my predecessor. The Pharmaceutical Union, in writing to me, have stated "in the exercise of their professional responsibility, they believe that arrangements should be made by agreement to ensure that medical card holders will not be deprived of essential drugs and medicines in the ensuing period", that is the period after 21st April, 1975. I shall be glad to discuss this matter with them.
Finally, I would ask the House to join me in urging these two professions to look at their situation in the context of the general economic position with which we are now faced. Doctors and pharmacists are not unreasonably remunerated and have secure incomes. They are, like any other section of the community, entitled to act to protect their financial position and to maintain relativities which they have enjoyed. But the current economic situation has required, and is continuing to require, moderation from all sections of the community. It is not unreasonable for us to ask, from those sectors of it which enjoy higher levels of remuneration than average, a recognition of the fact that further improvement in their position can only be achieved at the expense of other sections of the community. The extra annual Exchequer expenditure involved in meeting these claims would be about £13 million.
I think we would all be very grateful to the Minister for that long review which he has given us of the present difficult situation. However, it raises so many issues that it is difficult for me to pursue individual aspects of these two disputes with the Minister. Perhaps I might at this stage give notice that I should like to raise this matter on the Adjournment.
The Chair will communicate with the Deputy.
In the meantime, may I just ask the Minister a couple of questions? First of all, would the Minister agree that the pharmacists represent a very important, responsible and mature element of the general medical services and that they are skilled, trained people who have given excellent service to the community in their capacity as pharmacists down the years? Would the Minister agree that is so?
I have no doubt about that. This is not in contention.
If he agrees that is so, would he furthermore agree that since the changeover to administering these drugs and medicines service to the pharmacists has taken place, pretty universal satisfaction has been expressed by the general public as to the changeover of the services now rendered by the pharmacists' profession? Would the Minister agree with that?
Yes. Does the Deputy want to raise this on the Adjournment or to question me?
Both.
I have no doubt about the importance and the ability and the skill of both professions, but that is not in question.
I just want to establish that point.
The Deputy did not expect me to say they were all blackguards or something like that?
I just want to elucidate these statements from the Minister. Would he furthermore accept that many pharmacists have indicated that to continue under the present scheme and at the present rates of remuneration would involve their going bankrupt? Would the Minister accept that?
I must confess that there is no such evidence available to me. I do not know whether that sort of evidence is available to the Deputy. Their ability is not in question. Frankly, what is in question is what the fees should be. The Deputy has asked me to agree with him on certain things. Would he agree that in accordance with the original agreement made by the late Deputy Childers where the two sides could not come to an agreement the matter should go—the actual words are "shall go"—to arbitration? The pharmacists are not prepared to do that. As I indicated in my reply, I am quite willing to talk to them and to talk to the doctors' associations.
Would the Minister confirm that when this arrangement was first undertaken it was clearly understood by everybody that it was temporary, experimental and would necessarily be subject to review at an early date?
Yes.
Does the Minister further agree that the time to make that fundamental review has now come?
No. The review started on 29th March of last year, in respect of the pharmacists, and around the same time for the doctors.
Would the Minister agree that, if the pharmacists do not wish to go to arbitration, they are perfectly entitled not to go and that, in those circumstances, the sensible thing is for him to negotiate with them directly and resolve this matter in the interests of the general public, and particularly in the interests of those in receipt of general medical services?
Yes, and the latter section of the community the Deputy mentioned are my primary concern. I have indicated in my reply that, at their request, I will meet them.
The Minister will be negotiating directly with them?
To discuss the situation.
The Minister will not adopt the stance that they must go to arbitration if they do not want to go to arbitration?
I will not commit myself on that right now.
Is Deputy Haughey advocating that they should break the agreement? He was asked a question and he would not answer it. The Minister asked the Deputy does he not agree that they should honour their agreement and he refused to answer that question.
I did not hear that question.
I want to bring in Deputy Dr. Gibbons.
I am in favour of everybody honouring agreements but agreements can be interpreted differently. I am quite satisfied with the information I am getting from the Minister, thank you very much, Parliamentary Secretary.
I am not satisfied with the information the Deputy is giving.
I am not giving any information. I am asking questions. The information which the Minister is giving the House can be useful and, perhaps, may contribute to a solution to this very serious, difficult situation, a situation which, I may say, should not be used by the Parliamentary Secretary for political play.
Or you.
Your contributions to this House are very valuable at all times.
I was not jailed for them.
Please, Deputies.
If you want to go into that maybe some of your family should have been.
You should be.
If I had your family background I would keep very quiet about those sort of things.
Publish what you like. Go ahead.
Deputy Haughey has asked me a question. It is pretty clear in the agreement which was made when the scheme was first established —the agreement made between the late Deputy Childers as Minister for Health and the pharmaceutical organisations in respect of arbitration—that in the event of non-agreement they shall go to arbitration. "Shall" is the word.
Would the Minister not agree that he has overstated the case against the doctors by emphasising what is, in fact, the highest fee and one which must be very rare indeed, that is, the fee at night for a distance over ten miles when, in fact, it is built into medical administration that patients must opt for a doctor seven miles from them? In my area I think it would be true to say that no doctor would be in a position to collect this fee under the system of administration——
I must advise the Deputy that the period for Question Time is now exhausted.
Would the Minister also agree that he overstated the case when he referred to doctors having one-third of their patients on the medical services? In fact I have 55 per cent and this must be the figure which obtains for the western seaboard. I think it is overstating the case against the doctors to say that they have just one-third. Some doctors may, in fact——
The Deputy is making a speech instead of asking a question.
Will the Minister agree that the basis of the disagreement between the doctors and the Department is on the basic fee of 80p and not on the fee of £5 or £13 after midnight? I would ask the Minister to see that this is settled.
I do not think I could be accused of overstating the case in favour of one or the other. I tried to make the reply as objective as I could. It is a fact that the 80-90p is the crunch figure but I think it is incorrect for the Deputy to say that one-third of the population only are catered for under the GMS scheme. One-third is correct as far as the national average is concerned but when one goes over to the western counties the percentage is a bit higher. I should also say that in respect of some of the rural doctors who live in remote areas and cater for a certain population, there is an annual allowance for them also.
I am sorry to interrupt but the time for questions is up.
All the things the Deputy has said about money were considered by the arbitrator before he made the award, as the Deputy is aware.
The remaining questions will appear on tomorrow's Order Paper.